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Purpose The present study aims to investigate the surface characteristics and biomechanical properties of 3D-printed polycaprolactone (PCL) mesh and present the clinical outcomes of this implant in the treatment of orbital wall fractures. Patients and method A retrospective review of patients who underwent surgery for medial, inferior and inferomedial orbital wall fractures using PCL mesh was performed between April 2017 and June 2018. Two clinical outcomes were investigated: functional recovery and anatomical accuracy of reduction detected in image. Furthermore, scanning electron microscopy was used to evaluate the microscopic morphology, surface characteristics, and porosity of the PCL mesh. Results Among a total of 22 patients with a mean age of 41.3 years, the most common cause of injury was assault (54.5%). Fourteen patients (63.6%) had isolated orbital floor fractures. At postoperative 1-week follow-up, three patients (13.6%) exhibited diplopia and a further three patients (13.6%) showed restriction in ocular motility, but these patients had completely recovered by their 6-month postoperative follow-up. Ideal repair of orbital fracture was almost achieved in 21 patients (95.4%) and there were no cases of implant infection, inflammatory response, migration of implant, or hemorrhage. Microscopic imaging of PCL mesh surface revealed fully interconnected micropores with 50% porosity. Conclusions The repair of orbital wall fracture using PCL mesh offers reliable stabilization of orbital wall defects with a low complication rate, leading to outstanding functional and aesthetic outcomes. Therefore, PCL mesh is a good alternative for bioresorbable implants in the treatment of orbital wall fractures.

Background In this systematic review and meta-analysis, the authors examine the efficacy of antibiotic prophylaxis (AP) and specific antibiotic regimens for prevention of dental implant failure in patients who are healthy overall. Types of Studies Reviewed The authors independently conducted electronic database and manual searches to identify randomized controlled trials (RCTs). The authors selected articles on the basis of eligibility criteria and assessed for risk of bias by using the Cochrane Handbook. Implant failure was the primary outcome studied; perimucositis or implantitis, prosthetic failure, and adverse events were secondary outcomes studied. The authors conducted random effects meta-analysis for risk ratios of dichotomous data and used OpenMeta[Analyst] (Center for Evidence Synthesis, Brown School of Public Health) for qualitative assessment of administration schedules. Results With duplicates removed, the authors screened 1,022 abstracts, reviewed 21 full-text articles, and included 8 RCTs that included 2,869 implants in 1,585 patients. Meta-analysis results indicated that AP resulted in a statistically significantly lower number of implant failures for all regimens combined (implant, P = .005; patient, P = .002), as well as preoperative (implant, P = .01; patient, P = .007), pre- and postoperative (implant, P = .04), and postoperative AP only (implant, P = .02), compared with no antibiotics. The authors found no statistically significant differences in analysis of comparative antibiotic treatments or secondary outcomes. The authors identified confounding variables. Conclusions and Practical Implications Although meta-analysis results suggested that AP may reduce implant failure, definitive conclusions cannot be achieved yet. The overall nonsignificant differences reported in individual trials, limitations discussed, implant infection outcomes, and antibiotic-associated risks must be considered. Thus, the results for implant failure outcomes may not warrant the indiscriminate use of antibiotics in patients who are healthy who are receiving dental implants. Investigators must conduct large-scale RCTs to determine the efficacy of AP and various regimens, independent of confounding variables.

Prosthetic breast implantation is a common surgical procedure for augmentation and reconstruction after mastectomy. The incidence of implant infection is 1% to 2.5% and is higher for reconstruction following mastectomy compared with augmentation. Most infections are caused by gram-positive pathogens, such as coagulase-negative staphylococci, Cutibacterium species, Staphylococcus aureus, and streptococci. Acute infections are usually associated with fever and breast pain, erythema, and drainage. Subacute infections may present with chronic pain, persistent drainage, failed healing of the incision site, or migration of the implant. Depending on severity of infection, patients are started on empiric intravenous or oral antibiotics and closely monitored.

CAD-CAM patient-specific implants offer cerebral protection and improved facial balance without the disadvantages of autologous bone grafting such as donor site morbidity and unpredictable resorption. Several alloplastic materials are available, but titanium, polymethylmethacrylate (PMMA), and polyetheretherketone (PEEK) are the current popular choices. We reviewed our experience of applying different alloplastic CAD-CAM materials in the reconstruction of complex pediatric craniofacial deformities.A retrospective review was performed of all pediatric patients who underwent a complex inlay or onlay implant craniofacial reconstruction using CAD-CAM PEEK, PMMA, or titanium implants at a single institution. Demographics, cost, operative time, complications, and outcomes were assessed.Between 2003 and 2014, 136 patients (69 male; 67 female; mean age 11.5 years (3-22 years); mean follow-up 30 months) had custom patient-specific craniofacial reconstruction with PEEK (n = 72), PMMA (n = 42), and titanium (n = 22) implants (inlay = 93; onlay = 43). Indications included congenital anomalies (26.5%), decompressive craniectomies (25.0%), craniofacial syndromes (25.7%), tumor defects (14.0%), and post-trauma (6.6%). Implant cost varied significantly for PEEK ($7703 CAD) and PMMA ($8328 CAD) compared with that for titanium ($11,980 CAD) (p 0.0005). Six patients (4.4%) required surgery due to infection consisting of irrigation and antibiotic administration with successful implant salvage in three patients. All infections occurred in the PEEK group. Five patients (3.7%) ultimately had implants removed due to infection (n = 3), late exposure (titanium; n = 1), or late fracture (PMMA; n = 1).CAD-CAM alloplast reconstruction in the management of complex pediatric craniofacial deformities is effective although expensive. Implant infection does not always require explantation. A reconstruction algorithm is presented.

Implant related infection is relatively unusual in surgery to the hand and distal upper limb. When such infections occur, the consequences can be devastating. We review the latest guidance and research on the prevention, diagnosis, and management of implant-associated infections in the hand and distal upper limb.

Tissue damage caused by hyperthermia during photothermal therapy (PTT) has largely limited its clinical applications for implant infection. However, rescue of tissue regeneration by conjugating orthobiologics with PTT has been problematic as they can easily deactivate biologics while eradicating bacteria. Herein, we report an orthobiologics-free strategy to synergistically couple photocatalytic antibacterial with pro-osteogenic capacity via self-assembly of copper sulphide nanoparticle (CuS NP) and reduced graphene oxide (rGO) on implant surface. This strategy not only offers enhanced photothermal effects for bacterial eradiation via near-infrared light (NIR), but also promotes vascularized osseointegration via cooperation of copper ion with rGO. In vitro and in vivo data showed that coupling CuS and rGO synergistically increased antibacterial efficacy of implants by 40 times and successfully destroyed bacterial biofilm upon NIR. Moreover, CuS/rGO decorated surface substantially improved bone marrow stromal cell adhesion, proliferation, as well as subsequent differentiation toward osteoblast. We also revealed that enhanced peri-implant vascularization may be attributed to the sustained release of copper ion from CuS NPs, which further collaborated with rGO to promote vascularized osseointegration. Altogether, this novel orthobiologics-free approach offers a practical alternative to circumvent the intrinsic drawbacks of PTT and endows powerful antibacterial and pro-osteogenic capacities for implant associated infections.

Summary Purpose When an implant becomes infected, implant salvage is often performed where the implant is removed, capsulectomy is performed, and a new implant is inserted. The patient is discharged with a PICC line and 6–8 weeks of intravenous (IV) antibiotics. This method has variable success and subjects the patient to long-term systemic antibiotics. In the 1960s, the use of antibiotic-impregnated beads for the treatment of chronic osteomyelitis was described. These beads deliver antibiotic directly to the site of the infection, thereby eliminating the complications of systemic IV antibiotics. This study aimed to present a case series illustrating the use of STIMULAN calcium sulfate beads loaded with vancomycin and tobramycin to increase the rate of salvage of the infected implant and forgo IV antibiotics. Methods A retrospective analysis was performed of patients who were treated at Mount Sinai Hospital for implant infection with salvage and antibiotic beads. Results Twelve patients were identified, 10 of whom had breast cancer. Comorbidities included hypertension, smoking, and immunocompromised status. Infections were noted anywhere from 5 days to 8 years postoperatively. Salvage was successful in 9 out of the 12 infected implants using antibiotic bead therapy without home IV antibiotics. Conclusions The use of antibiotic beads is promising for salvaging infected breast implants without IV antibiotics. Seventy-five percent of the implants were successfully salvaged. Of the three patients who had unsalvageable implants, one was infected with antibiotic-resistant Rhodococcus that was refractory to bead therapy and one was noncompliant with postoperative instructions.

Summary Background Implant infections in the setting of breast reconstruction present a significant setback for patients with breast cancer. Traditional management of implant infections is predicated on the operative removal of the implant and delayed replacement. Another option for implant infection management has emerged in which the soft tissue infection is neutralized, the implant is removed, the surgical site is washed out, and a new implant replaced immediately. In this study, we present our findings with the implementation of this technique and an algorithm for choosing which patients are the most appropriate candidates on the basis of a retrospective review. Methods A retrospective chart review of patients who underwent operative removal of infected expanders from January 1, 2010 to December 31, 2015 was performed at the University of Michigan by the senior authors. The final reconstructive outcome, time to reconstruction, and infection recurrence were evaluated. Results Twenty patients with clinical signs of implant infections were identified. Of them, 16 patients with clinical signs of implant infection underwent immediate implant exchange; 15 remained infection free, while 1 patient developed recurrent infection within a month, which was treated with device removal. The mean time to final reconstruction in the 15 infection free patients was 207 days, and the 4 patients who underwent removal without immediate replacement had a 75% rate of non-completion at over 500 days. Conclusions Our findings demonstrate that immediate implant exchange safely offers patients the opportunity to remain on a path toward reconstruction. These findings offer support for a paradigm shift in our management of implant infections in breast reconstruction patients who already face challenges associated with breast cancer care.

BACKGROUND CONTEXT Recent studies have indicated that allogenic blood transfusions are a risk-factor for surgical site infections (SSI) after orthopedic surgery. Previously, our lab observed that blood transfusions promoted a soft-tissue infection as opposed to an implant infection using our mouse model of spine implant infection with gram-positive (GP) Staphylococcus aureus. It is unknown if similar effects will be seen with gram-negative Pseudomonas aeruginosa. PURPOSE To examine how blood transfusions affect GP vs GN bacterial SSI using a mouse model of spine implant infection. STUDY DESIGN/SETTING Not applicable. PATIENT SAMPLE Not applicable. OUTCOME MEASURES Not applicable. METHODS Eight- to 12-week-old C57BL/6 mice were used in this experiment. To model a spine implant infection, a stainless-steel k-wire was surgically placed in the L4 spinous process and inoculated with either a bioluminescent strain of Staphylococcus aureus (Xen36) or a bioluminescent strain of Pseudomonas aeruginosa (Xen41). All mice were transfused immediately postoperatively and on postoperative day (POD) 1 with 200 microliters of blood or saline (no blood group). In vivo bioluminescent imaging (BLI) was used to quantify bacterial burden postoperatively. Mice were sacrificed at the end of the experiment (POD28) and paraspinal tissue and spine implants were collected and used to obtain colony-forming units (CFUs). RESULTS All infected mice demonstrated increased BLI signal compared to sterile controls. From POD3 to POD7, S. aureus infected mice that received blood transfusions had higher average BLI signal compared to the mice that received no blood. From POD3 to POD7, P. aeruginosa infected mice that received blood transfusions had lower average BLI signal compared to the mice that received no blood. CFU analysis revealed no difference in the soft-tissue infection rates between the S. aureus and the P. aeruginosa infected mice that received blood transfusions (93% vs 100% respectively, p=0.3218). CFU analysis revealed a significant difference in the spine implant infection rates between the S. aureus and the P. aeruginosa infected mice that received blood transfusions (40% vs 100% respectively, p=0.0006). CONCLUSIONS As we continue to learn more about spine implant infections, one essential concept that is becoming clearer is that not all biofilm-mediated implant infections are the same. For instance, both GP and GN bacteria can form biofilms and cause chronic infection, but our findings suggest that these two groups of bacteria react differently to the same stimulus (blood transfusion) in the context of biofilm-mediated implant infections. We believe that our results warrant additional similar in-vivo studies which will continue to clarify the intricate pathophysiology behind spine implant infections and prevent the gross over-simplification of a complex clinical problem. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Purpose Diabetes mellitus is a risk factor for morbidity and mortality in patients with heart failure. The effect of pre-implant diabetes control on left ventricular device (LVAD) outcomes and specific types of infection is unclear. Prior studies have found that diabetes is associated with an increased rate of all-cause mortality and major adverse events during LVAD support, while others have shown that diabetes is not associated with major adverse events, including infections. The purpose of our study was to understand the relationship of pre-LVAD hemoglobin A1c on post implant infection. Methods We analyzed 2054 patients from the INTERMACs registry who were implanted with an LVAD and had a hemoglobin A1c level checked between Jan 2016-Dec 2017. The association between pre-implantation hemoglobin A1c and post-implant infection within 90 days was assessed using a cox proportional hazards model. Results Pre-implant hemoglobin A1c levels had no significant association with post-LVAD infections within 90 days of follow-up (HR 1.02 [95% CI 0.96-1.09], p 0.544). Furthermore, this lack of association did not vary within subgroups of infection type (driveline, bloodstream, pulmonary, or urinary tract). (Figure 1) Conclusion Based on this large database, pre-LVAD hemoglobin A1c is not a predictor of early post-LVAD infection. Further studies are needed to better understand the relationship of hemoglobin A1c as it relates to clinical outcomes after LVAD implantation.

Background Molecular procedures could potentially improve diagnoses of orthopaedic implant-related infections, but are not yet clinically implemented. Analysis of sonication fluid shows the highest sensitivity for diagnosing implant infections in cases of revision surgery with implant removal. However, there remains controversy regarding the best method for obtaining specimens in cases of revision surgery with implant retention. Tissue culture is the most common diagnostic method for pathogen identification in such cases. Here we aimed to assess the diagnostic performance of swab PCR analysis compared to tissue culture from patients undergoing revision surgery of fracture fixation devices. Methods We prospectively investigated 62 consecutive subjects who underwent revision surgery of fracture fixation devices during a two-year period. Tissue samples were collected for cultures, and swabs from the implant surface were obtained for 16S rRNA PCR analysis. Subjects were classified as having an implant-related infection if (1) they presented with a sinus tract or open wound in communication with the implant; or (2) purulence was encountered intraoperatively; or (3) two out of three tissue cultures tested positive for the presence of the same pathogen. Tissue culture and swab PCR results from the subjects were used to calculate the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and area under the ROC curve (AUC) for identifying an orthopaedic implant-related infection. Results Orthopaedic implant-related infections were detected in 51 subjects. Tissue culture identified infections in 47 cases, and swab PCR in 35 cases. Among the 11 aseptic cases, tissue culture was positive in 2 cases and swab PCR in 4 cases. Tissue culture showed a significantly higher area under the ROC curve for diagnosing infection (AUC = 0.89; 95% CI, 0.67–0.96) compared to swab PCR (AUC = 0.66; 95% CI, 0.46–0.80) ( p = 0.033). Conclusions Compared to swab PCR, tissue culture showed better performance for diagnosing orthopaedic implant-related infection. Although molecular methods are expected to yield higher diagnostic accuracy than cultures, it appears that the method of obtaining specimens plays an important role. Improved methods of specimen collection are required before swab PCR can become a reliable alternative to tissue-consumptive methods.

Implant associated infections are still key problem in surgery. In the present study, the combination of a magnetic implant with administered magnetic nanoporous silica nanoparticles as potential drug carriers was examined in mice in dependence of local infection and macrophages as influencing factors. Four groups of mice (with and without implant infection and with and without macrophage depletion) received a magnet on the left and a titanium control on the right hind leg. Then, fluorescent nanoparticles were administered and particle accumulations at implant surfaces and in inner organs as well as local tissue reactions were analyzed. Magnetic nanoparticles could be found at the surfaces of magnetic implants in different amounts depending on the treatment groups and only rarely at titanium surfaces. Different interactions of magnetic implants, particles, infection and surrounding tissues occurred. The general principle of targeted accumulation of magnetic nanoparticles could be proven.

Infections of medical implants caused by bacterial biofilms are a major clinical problem. Bacterial colonization is predicted to be prevented by alkaline magnesium surfaces. However, in experimental animal studies, magnesium implants prolonged infections. The reason for this peculiarity likely lies within the ‒still largely hypothetical‒ mechanism by which infection arises. Investigating subcutaneous magnesium implants infected with bioluminescent Pseudomonas aeruginosa via in vivo imaging, we found that the rate of implant infections was critically dependent on a surprisingly high quantity of injected bacteria. At high inocula, bacteria were antibiotic-refractory immediately after infection. High cell densities are known to limit nutrient availability, restricting proliferation and trigger quorum sensing which could both contribute to the rapid initial resistance. We propose that gas bubbles such as those formed during magnesium corrosion, can then act as interfaces that support biofilm formation and permit long-term survival. This model could provide an explanation for the apparent ineffectiveness of innovative contact-dependent bactericidal implant surfaces in patients. In addition, the model points toward air bubbles in tissue, either by inclusion during surgery or by spontaneous gas bubble formation later on, could constitute a key risk factor for clinical implant infections.

Antimicrobial photodynamic therapy (PDT) has attracted much attention for the treatment of pathogenic biofilm associated with peridontitis and peri-implantitis. However, data from randomized controlled clinical studies (RCTs) are limited and, to some extent, controversial, making it difficult to provide appropriate recommendations. Therefore, the aims of the present study were (a) to provide an overview on the current evidence from RCTs evaluating the potential clinical benefit for the additional use of PDT to subgingival mechanical debridement (ie, scaling and root planing) alone in nonsurgical periodontal therapy; and (b) to provide clinical recommendations for the use of PDT in periodontal practice.

BACKGROUND CONTEXT Diagnosis and precise localization of spine infections are an elusive pursuit. Despite widespread technical advances, the current standard of magnetic resonance imaging lacks the precision to discern infection versus inflammation due to other causes. Nuclear medicine utilizing the metabolic positron emission tomography (PET) probe18F-fluorodeoxyglucose (18F-FDG) can identify inflammation, but it lacks specificity for bacterial infection. However, adjuncts compatible with PET/CT imaging have the potential to noninvasively increase the specificity for bacteria responsible for spine infections and guide surgeons with regard to the locale and extent of infection. PURPOSE The purpose of this study is to assess the diagnostic potential of utilizing PET/CT and 89-Zirconium (89Zr) labeled bacterial probes in noninvasive, accurate localization of spine implant infections. STUDY DESIGN/SETTING This is a basic science investigation utilizing a mouse model of spine infection. The spine implants are inoculated with bioluminescentStaphylococcus aureusfor longitudinal quantification of bacterial burden, and PET/CT signal intensity is quantified utilizing 18F-FDG and 89Zr-DFO-1D9 mAb intravenous injections. PATIENT SAMPLE Fifteen12-week-oldC57BL/6 wild type mice were utilized. OUTCOME MEASURES In vivobioluminescence and PET/CT signal intensity was quantified utilizing imaging software. Three-dimensional PET/CT images were utilized to localize signal intensities of interest. METHODS In accordance with an established mouse model of spine implant infection, a spinal implant was fixed into the spinous process of the L4 vertebra. Inoculation of the implant and wound bed was performed with bioluminescent S. Aureus. On postoperative day 7, 18F-FDG PET/CT imaging was completed in 11 infected and four sterile control mice. They were also injected intravenously via lateral tail vein with 68.6±1.6 μCi (∼14μgmAb) of89Zr-DFO-1D9 mAb. One week following89Zr-DFO-1D9 injection, mice underwent PET/CT to detect 89Zr-DFO-1D9 mAb signal intensities. RESULTS Bioluminescence imaging revealed signal emitted solely from the surgical bed of infected mice which matched that of historical infected controls – bioluminescence signals remained elevated over the duration of the experiment suggestive of sustained bacterial infection. PET-CT imaging with 18F-FDG probe revealed high signal intensity at the site of the spine implant with lower levels of signal within the gut, bladder, and heart. The 89Zr-DFO-1D9 mAb probe signal in the region of the implant was significantly higher in infected mice compared to sterile controls (2.72e9±1.19e9 versus 6.60E8±3.56E8 total radiant efficiency, respectively;p CONCLUSIONS TheS. aureusspecific89Zr-DFO-1D9 mAb probe was shown by PET/CT imaging to accurately detectinfections in-vivo. This study represents the first in-vivo investigation utilizing PET/CT with intravenous bacterial specific probes which may vastly improve the ability to accurately and noninvasively diagnose and localize spine infections.

BACKGROUND CONTEXT Bisphosphonates are commonly used in the orthopedic patient population to manage osteoporosis and other metabolic bone diseases. There is also increasing support for bisphosphonate use in the perioperative setting, to minimize osteolysis and bone loss. Additionally, bisphosphonates are known to affect the host immune system; however, their effect on implant infections, which are notoriously difficult to treat, remains largely unknown. PURPOSE The purpose of this study was to assess the effect of zoledronic acid (ZA) on spinal implant infection in our validated mouse model. METHODS Twenty-six 8-week-old C57BL/6 mice were included in the study. Twelve were treated with 250 ug/kg of ZA,12 with normal saline via retro-orbital injection on the day of surgery, and the remaining 2 were sterile controls. A stainless steel pin was then placed into the L4 spinous processes of all mice and site was inoculated with 1E+3 CFUs of bioluminescent Xen36 Staphylococcus aureus in experimental groups. Infection burden was monitored with in vivo bioluminescence imaging at pre-determined intervals. RESULTS Following an initial similar increase after surgery and inoculation, mice treated with ZA showed a decreased bacterial burden as compared to infected control group (p CONCLUSIONS The indications for ZA use continue to expand, and it is often used in the perioperative setting. In our validated mouse model of spine implant infection, ZA decreases bacterial burden as compared to controls. Further investigation is required to determine the effects of dosing, location of infection and to explore possible mechanisms by which ZA exerts this effect. These findings may suggest a further benefit to bisphosphonate use in the perioperative setting. FDA DEVICE/DRUG STATUS Unavailable from authors at time of publication.

BACKGROUND CONTEXT In the US, approximately 5-10% of spine surgery patients require postoperative blood transfusions. It is unclear whether or not blood transfusions increase risk of postoperative infections in these patients. Interestingly, while current regulations allow for blood to be stored up to 42 days, recent studies have suggested that prolonged storage may influence postoperative infection risk. PURPOSE The purpose of this study was to compare effects of “old” and “fresh” blood transfusions on infection burden in a mouse model of spine implant infection. METHODS C57BL/6 mice were bled aseptically by cardiac puncture for blood collection. Blood was stored for 12 days (old blood) or 1 day (fresh blood) prior to transfusion (both samples were within acceptable transfusion criteria). To model a spine implant infection in C57BL/6 mice, a stainless-steel wire was surgically placed in the L4 spinous process and inoculated with a bioluminescent strain of Staphylococcus aureus. Mice were transfused immediately postoperatively and on postoperative day (POD) 1 with 200 microliters of either old blood, fresh blood, or no blood (saline). In vivo bioluminescent imaging (BLI) was used to quantify bacterial burden postoperatively. RESULTS All infected mice demonstrated increased BLI compared to sterile controls. On POD3, mice transfused with old and fresh blood had higher average BLI compared to mice who received no blood. On POD7 and POD10, mice transfused with old blood demonstrated higher average BLI than both fresh and no blood groups. CONCLUSIONS Transfusion of old blood in our mouse model of spine implant infection resulted in persistently elevated BLI compared to fresh blood and no blood groups. These findings suggest that storage duration of blood products may indeed increase infection burden and emphasize the need for further research in this area. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background Hepatitis C virus (HCV) is associated with poorer outcomes in total joint arthroplasty (TJA). Recently, oral direct-acting antivirals (DAAs) have become available for HCV curative treatment. The goal of this study is to determine if HCV may be a modifiable risk factor in TJA by comparing postoperative complications among patients with and without preoperative treatment for HCV. Methods US Department of Veterans Affairs dataset of all consecutive primary TJAs performed between 2014 and 2018, when DAAs were available, was retrospectively reviewed. HCV-infected patients were identified using International Classification of Diseases, Ninth and Tenth Revision codes and laboratory values. HCV-infected patients treated prior to TJA with DAA were included in the “treated” group. HCV-infected patients untreated preoperatively were assigned to the “untreated” group. Medical and surgical complications up to 1 year postoperatively were identified using International Classification of Diseases, Ninth and Tenth Revision inpatient and outpatient codes. Results In total, 42,268 patients underwent TJA at Veterans Affairs Hospitals between 2014 and 2018. About 6.0% (n = 2557) of TJA patients had HCV, 17.3% of whom received HCV treatment preoperatively. When evaluating inpatient and outpatient codes, implant infection rates were statistically lower at 90 days and 1 year postoperatively among HCV-treated patients than among those untreated. Odds ratios (ORs) favor lower infection rates in HCV-treated patients (90-day OR: 3.30, P = .045; 1-year OR: 2.16, P = .07). Conclusion Preoperative HCV treatment was associated with lower periprosthetic infection rates among US veterans undergoing TJA. Further investigation is necessary for definitive conclusions.

Infection is currently regarded as the most severe and devastating complication associated to the use of biomaterials. The important social, clinical and economic impacts of implant-related infections are promoting the efforts to obviate these severe diseases. In this context, the development of anti-infective biomaterials and of infection-resistant surfaces is being regarded as the main strategy to prevent the establishment of implant colonisation and biofilm formation by bacteria. In this review, the attention is focused on the biomaterial-associated infections, from which the need for anti-infective biomaterials originates. Biomaterial-associated infections differ markedly for epidemiology, aetiology and severity, depending mainly on the anatomic site, on the time of biomaterial application, and on the depth of the tissues harbouring the prosthesis. Here, the diversity and complexity of the different scenarios where medical devices are currently utilised are explored, providing an overview of the emblematic applicative fields and of the requirements for anti-infective biomaterials.

Prevention of surgical site infection in orthopaedic surgery and bone trauma has some hallmarks not shared with other surgical disciplines: low inoculum for implant infections; pathogenicity of coagulase-negative staphylococci and other skin commensals; possible haematogenous origin; and long post-discharge surveillance periods. Only some of the many measures to prevent orthopaedic surgical site infection are based on strong evidence and there is insufficient evidence to show which element is superior over any other. This highlights the need for multimodal approaches involving active post-discharge surveillance, as well as preventive measures at every step of the care process. These range from preoperative care to surgery and postoperative care at the individual patient level, including department-wide interventions targeting all healthcare-associated infections and improving antibiotic stewardship. Although theoretically reducible to zero, the maximum realistic extent to decrease surgical site infection in elective orthopaedic surgery remains unknown.

Medical implants have been rarely associated with the development of sarcomas. We report, to our knowledge, the first case of a high-grade epithelioid angiosarcoma developing in the capsule of an internal cardiac defibrillator implanted subcutaneously over the abdomen over 20 years ago. Although the internal cardiac defibrillator generator had been exchanged in the intervening years, recently, the patient showed a year-long history of systemic symptoms suspicious for implant infection, necessitating several internal cardiac defibrillator pocket hematoma evacuations, always with negative microbiologic cultures. Final reexploration identified suspicious tissue with excessive bleeding which was biopsied and proven to be angiosarcoma on histologic examination. Subsequent imaging demonstrated precipitous progression to liver and lung metastases. Though rare, foreign-body-related sarcoma should be considered in the differential diagnosis for presentations suggestive of hemorrhagic or infectious sequelae of medical implants; this case broadens the range of medical devices associated with angiosarcoma to include now very commonly used implantable medical devices.

Background MRSA is a major economic and health issue internationally and as such is of particular importance in the appropriate management of orthopaedic patients. Bone, joint and implant infection can lead to unfavourable outcomes with a long protracted in hospital stay inevitable. The cost for the patient, the hospital and society are substantial. Materials and methods This study was a review of a prospectively maintained database from our unit over three time points from 2005 to 2007. At each time point a new infection control measure was implemented in an effort to reduce MRSA infections. Total rates of MRSA infection and colonisation in all orthopaedic patients were recorded, before and after separation of trauma and elective services, and after the introduction of a screening pre assessment clinic. Results 12259 orthopaedic patients were reviewed over the three years. The mean age of MRSA infected patients was 71. A higher proportion of female patients were infected than male patients. The mean length of stay for infected patients was 23.4 days. The rate of infection dropped from 0.49% in 2005 to 0.24%in 2007. After the introduction of these measures there was a substantial reduction in organ space and deep tissue infections. Conclusion The separation of emergency and elective orthopaedic services coupled with effective pre-operative screening has resulted in a significant reduction in MRSA infection despite an ever increasing prevalance.

Summary Background Traditional single-stage breast reconstruction with autologous tissue leaves an obvious skin island. Alternatively, a staged reconstruction with the creation of a skin envelope with a tissue expander which is then replaced with a de-epithelialised flap, leaves a breast with the original mastectomy scar and no skin island. Methods Consecutive patients who underwent the two-stage reconstruction between 2004 and 2010 were included in the study. Data were collected retrospectively on patient demographics, adjuvant treatments, surgical procedures and outcomes. Results A total of 65 patients who initially had a non-skin sparing mastectomy underwent two-stage breast reconstruction, of which the majority were delayed ( n = 63, 95%) and unilateral ( n = 64, 98.5%). Each patient was individually assessed for their suitability for the two-stage reconstruction. In 89% ( n = 58) of cases, the expander was inserted in a subcutaneous pocket, while in the remaining a subpectoral pocket was elected. After the first stage, seven complications were recorded (10.7%), notably three expander extrusions, three seromas and one implant infection. Of the 65 patients, 63 proceeded to the second stage of reconstruction with 38 transverse rectus abdominis myocutaneous (TRAM) (60%), 12 superficial inferior epigastric artery (SIEA) (19%), and 13 deep inferior epigastric perforator (DIEP) (21%) flaps. Mean follow-up time since the completion of the second stage was 42 months (range 6–80 months), with complete flap loss recorded in 4.6% and minor fat necrosis in 9.5% of cases. Conclusions The two-stage breast reconstruction using skin expansion and autologous tissue transfer eliminates the need for a visible skin paddle and produces a sensate breast with a more natural-looking breast mound.

Summary This case report describes an unusual case of a 55-year-old male, who presented with what appeared to be a pseudomeningocoele. The patient suffered a skull fracture secondary to a direct blow almost 30 years prior, and had been repaired with a calvarial implant at that time. He had been symptom free for most of that time, until he presented to our institution with a bulging cyst in his left frontal region. Computed tomography revealed a calvarial defect at the site of the cyst and a presumptive diagnosis of pseudomeningocoele was made. As part of his treatment, the patient underwent a lumbar puncture and lumbar peritoneal shunt. These procedures, although temporarily beneficial, ultimately proved unsuccessful in permanently decreasing the size of the cyst. After all conservative measures were exhausted, the team surgically explored the patient: while no communication between the cerebrospinal fluid and cyst could be found, which would be expected in a pseudomeningocoele, there was fibrinous exudates on the implant surface. Tissue cultures showed Staphylococcus epidermidis . This case emphasises the importance of surgical exploration to make a correct diagnosis, as in this case of a sub-clinical calvarial implant infection 30 years after insertion of the implant.

金沢大学医薬保健研究域医学系, Deep infection remains a serious complication in orthopedic implant surgery. In order to reduce the incidence of implant-associated infections, several biomaterial surface treatments have been proposed. This study focused on evaluating the antibacterial activity of iodine-supported titanium (Ti-I 2) and its impact on post-implant infection, as well as determining the potential suitability of Ti-I2 as a biomaterial. External fixation pins were used in this experiment as trial implants because of the ease of making the septic models. The antibacterial activity of the metal was measured using a modification of the Japanese Industrial Standards method. Activity was evaluated by exposing the implants to Staphylococcus aureus or Escherichia coli and comparing reaction of pathogens to Ti-I2 vs. stainless steel and titanium controls. Ti-I2 clearly inhibited bacterial colonization more than the control metals. In addition, cytocompatibility was assessed by counting the number of colonies that formed on the metals. The three metals showed the same amount of fibroblast colony formation. Japanese white rabbits were used as an in vivo model. Three pins were inserted into both femora of six rabbits for histological analysis. Pin sites were inspected and graded for infection and inflammation. Fewer signs of infection and inflammatory changes were observed in conjunction with the Ti-I2 pins. Furthermore, osteoconductivity of the implant was evaluated with osteoid formation surface of the pin. Consecutive bone formation was observed around the Ti-I2 and titanium pins, while little osteoid formation was found around the stainless steel pins. These findings suggest that Ti-I2 has antimicrobial activity and exhibits cytocompatibility. Therefore, Ti-I2 substantially reduces the incidence of implant infection and shows particular promise as a biomaterial. © 2010 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Locally applied antibiotics support prophylaxis of highly feared implant associated infections. Implant coatings with poly(D,L-lactide) (PDLLA)/gentamicin seem to be a promising approach. Aims of this study were to analyse the release kinetics of gentamicin in vivo, in vitro, to analyse the antibacterial efficacy,the resistance development and its impact on osteoblasts. For the in vitro release experiments titanium implants were coated with PDLLA/gentamicin and the antibiotic release in aqueous solution was analysed at 20 time points (from 10 s to 110 days). For the in vivo experiments PDLLA/gentamicin-coated kirschner wires were implanted in the tibiae of 18 rats. Gentamicin concentration in the bone was analysed at several time points (n = 3 each, 1 h to 7 days). Bactericidal efficacy, bacterial adhesion on the implants and resistance development were tested. AP activity, cell count and CICP expression of osteoblasts were analysed. Gentamicin was released rapidly with an initial burst in aqueous solution and followed by a slow release. Similarly, in vivo gentamicin concentration reached a high peak initially followed by a decrease to a low level. No development of resistance was observed in the investigated setting, the antibacterial efficacy was not affected by the coating process and significantly fewer bacteria were attached to the implant. Osteoblasts were not negatively affected by the gentamicin released from the coating. PDLLA/gentamicin coating resulted in a desired antibiotic peak concentration within the bone. Bacterial adhesion was successfully prevented. No bacterial resistances were developed. This coating seems to be a suitable supplement for prophylaxis of implant-associated infections.

BACKGROUND CONTEXT Surgical debridement of spine infections consists of excising tissue at the surgeon's discretion. Surgeon's rely on visual cues such as abnormal tissue coloration and consistency to determine the extent of debridement. However, complete and accurate debridement is difficult to assess given the lack of objective data with regard to location and extent of residual infection. PURPOSE The purpose of this study is to apply two emerging technologies: (1) novelStaphylococcus aureustargeting fluorescently labeled probes and (2) “OR ready” real-time fluorescent imaging system, in a proof of principle study evaluating the feasibility of image-guided debridement surgery. STUDY DESIGN/SETTING This is a basic science investigation utilizing a mouse model of spinal implant infection. BioluminescentStaphylococcus aureusis used for longitudinal quantification of bacterial burden. Once infections were established, an open-air, “OR ready” fluorescent imaging system was utilized for image guided surgery. PATIENT SAMPLE Thirty-six 12-week-oldC57BL/6 wild type mice were utilized, 10 for each experimental group. OUTCOME MEASURES Utilizing an established mouse model of spinal implant infection,in vivobioluminescence and fluorescence imaging was performed to quantify emitted signals. A recently developed open-air, fluorescence input image-guided surgery system was utilized to for debridement surgery and to evaluate residual bacterial burden on debrided tissue. METHODS Three groups of mice were subjected to a previously established spine implant infection model: (1) five mice with implants inoculated withS. aureusand one sterile control mouse 60 days prior to image-guided debridement, (2) 10 inoculated and five sterile mice 30 days prior, (3) 10 inoculated and five sterile control mice 7 days prior. A total of 24 hours prior to debridement surgery, aS. aureusImmunodominant Staphylococcal Antigen A (IsaA) antibody fluorescent probe was administered via tail vein injection. Fluorescent imaging was completed to confirm co-localization of the probe to bioluminescent bacteria. Mice were then subjected to a fluorescence image-guided surgery system for debridement. RESULTS Two of five mice from the 60-day group, 8/10 of the 30-day group, and 10/10 of the 7-day group established an infection confirmed by bioluminescence imaging. Subsequent fluorescence imaging following IsaA-antibody probe injection revealed co-localization of fluorescent probe to bioluminescent bacteria with high fidelity. Radical debridement of fluorescent material under the image-guided surgery system was completed which revealed fluorescently labeled tissue with continued light emissionex-vivo.No fluorescence remained in mice status post debridement, indicating successful infection excision. CONCLUSIONS The novel,S. aureusspecific fluorescent probe successfully labelled bacteria in chronic and acute spine implant infections.Furthermore, this probe was successfully applied to the image-guided surgery system.This technology has the potential to shift the paradigm in excision surgery with applications in infection and negative margin tumor surgery.

Summary Purpose The application of rhinoplasty in the treatment of traumatic nasal deformity remains one of the most challenging problems for surgeons. Not only is the skeletal structure severely deformed, but the soft tissue may also be disfigured by a previous injury. Although autogenous bone and cartilage have been the primary choice for nasal reconstruction, synthetic material is desirable for various reasons. This article presents our experiences in the reconstruction of traumatic nasal deformity by using porous polyethylene (Mdepor ® ) implant in Orientals. Materials and methods From May 1998 to January 2005, 32 patients, including 15 males and 17 females, underwent augmentation rhinoplasty for the correction of traumatic nasal deformity. Of these, 30 patients had experienced associated midfacial bone fractures. The surgical procedures employed consisted of the open-tip approach that was followed by implant carving, placement and fixation. Twenty patients received lateral nasal osteotomies, and septoplasty procedures were performed in nine patients, simultaneously. External taping was done, and nostril tampons were placed postoperatively and left in situ for 3 days. The outcome was assessed by an independent investigator and the patients themselves. Results The patients were, on average, 22 years old at the time of reconstruction and were followed up for an average period of 25.4 months. The interval from injury to the rhinoplasty procedure was 304 days, on average. The average length of dorsal grafts was 44.9mm. The overall aesthetic-improvement rate was 90.6%, and the patient-satisfaction rate was 84.4%. There were three complications, including an implant-tip exposure and two implant infections. Conclusion A porous polyethylene (Medpor ® ) implant is an effective alternative to autograft for correction of traumatic nasal deformity in Orientals to achieve a pleasing appearance of the nose without donor-site morbidity. A meticulous execution of concomitant procedures and impregnation of the implant by submerging it in an antibiotics solution prior to use were helpful in decreasing the complications.

Summary Introduction Implant infection is serious; prevention is mandatory, and requires assessment. The present study assessed the incidence of deep surgical-site infection (SSI) at 1 year following total knee arthroplasty (TKA) and adherence to skin preparation, antibiotic prophylaxis, screening and prevention in case of methicillin-resistant S. aureus (MRSA). Hypothesis Adherence to prevention measures reduces infection risk secondary to TKA. Material and methods A prospective study of the incidence of SSI following primary TKA was run from December 1st 2005 to December 31st 2006 in a continuous series of 364 operations in 359 patients, excluding cases of septic or aseptic revision. Each implant was followed up for 12 months. Adherence to practice was assessed by independent observers. Antibiotic prophylaxis was assessed; skin preparation was scored (out of 10); MRSA was systematically screened for, and preventive measures were assessed in positive cases. Median follow-up was 12 months. Patients with less than 11 months’ FU were contacted by telephone. Median age was 72 years (range, 45–92 years). Eighty-seven percent of patients had ASA scores of 2; 14% were diabetic, and 42% obese. Mean surgery time was 70 min (range, 30–164 min). Among the implants, 81.5% were cemented. Eighty-six percent of operations had NNIS scores of 0. Infection risk linked to theater environment and teams was under control. Results Fourteen patients were lost to follow-up and excluded from analysis. The incidence of infection was 1.4% (n = 5/350) (95% CI [0.41–3.22]). Three of the infections were early (≤ 1 month), and two were polymicrobial. Antibiotic prophylaxis was implemented correctly in 99% of cases, with skin preparation scores of 8.75 in 61% of cases and of 10 in 39%. Among the pattients, 2.5% were MRSA-positive, none of whom developed infection. Infection prevention measures were applied in only half of the MRSA-positive cases. No MRSA-positive patients developed SSI. Discussion SSI incidence in the present series was low, but certainly underestimated. Assessment found good implementation of infection prevention protocols, with SSI occurring randomly with regard to adherence parameters (antibiotic prophylaxis, skin preparation, MRSA status). Conclusion Our hypothesis could not be confirmed. The study was mandatory for a health-care institution, and indispensable from a legal standpoint. Level of Evidence Level IV. Prospective prognostic study.

Therapeutic conclusions for staphylococcal implant infections treated with debridement and implant retention can only be drawn from a small series. To this aim, data from patients with implant staphylococcal infections (1998–2006) treated with debridement and implant retention were retrospectively reviewed. Infections were defined by staphylococci isolation (two or more consecutive debridement or three sinus tract discharge samples) along with clinical criteria. Patients received oral levofloxacin plus rifampicin for ≥6 weeks after the resolution of signs/symptoms and C-reactive protein normalisation. Failure was defined as lack of response or recurrence of signs/symptoms and/or sinus tract bacterial isolation during therapy or follow-up and/or implant removal. Twenty-five patients (53.2 ± 20.8 years; 48% males) were included, 12 with spinal infections and 13 with limb implant infections. Diagnosis was performed from debridement material (72%) and sinus tract discharge (28%) (11 Staphylococcus aureus and 14 coagulase-negative staphylococci (CoNS)). Time from surgery to symptom onset was higher in CoNS infections compared with S. aureus infections (21.6 ± 9.3 days vs. 12.6 ± 5.2 days; P = 0.007). Seven patients (28%) were failures, with no differences between cured patients with respect to age, sex, infection site, time from surgery to symptom onset, sinus tract diagnosis and aetiology. Longer symptom duration prior to attendance was observed in failures (5.7 ± 6.2 months vs. 1.4 ± 0.6 months; P = 0.04). Levofloxacin plus rifampicin showed efficacy in implant infections, which was higher for short duration of symptoms.

Implant infection remains the major and often irreducible complication in clinical use of biomaterials, demanding new therapeutic and preventive strategies. Etio-pathogenesis of biomaterials-related infections is being more and more studied, and various virulence bacterial factors have progressively been identified, but little is still known about the weight of the distinct molecules in the context of specific peri-implant infection sites. Molecular epidemiology has become recently integrated into the research on implant infections. What distinguishes molecular epidemiology from the simple molecular biology is that the use of molecular techniques is applied to the study of the distribution and prevalence of virulence and resistance genes in collections of bacterial clinical isolates from implant infections. Here, the authors comment on the range of molecular techniques available, reviewing the various applications of molecular epidemiology to the study of implant infections and providing some experimental examples related to the field of orthopaedic implant infections. They highlight the new opportunities arising from molecular epidemiology of designing measures useful to prevent and treat implant infections. The knowledge of the relative weight of virulence factors and of their regulatory mechanisms at molecular level can open the way to new strategies also including gene therapies aimed at silencing or knocking out crucial genes responsible for the aggressive tools (adhesins, biofilm production, antibiotic resistance) of the aetiological agents of implant-related infections.

The most judicious way to address peri-implant disease is to take steps to avoid it from the beginning of each implant restoration case. This involves treatment planning with a priority placed on biomechanically overengineering the case, using sound surgical techniques, enhancing keratinized tissue prior to placing the implants when appropriate, and placing an emphasis on rigorous follow-up and hygiene instruction. In the long run, the benefits of adhering to such methods outweigh the disadvantages. Careful attention to these guidelines leads to a less stressful practice and fewer cases of peri-implantitis. It should also increase our dental implant success rates and predictability of outcome even further.

Infections after breast augmentation are uncommon, occurring in 1-3% of cases. Treatment often requires additional surgeries and may yield a sub-optimal cosmetic result. For this reason, post implant infection remains a serious concern among plastic surgeons. A 48-year-old female presented to our clinic with bilateral breast implant infections 3 months after primary augmentation in China. Cultures grew Mycobacterium abscessus, a previously undescribed infectious aetiology after breast augmentation. The fastidious nature of the organism often results in a negative acid fast stain and initially sterile cultures. For these reasons, clinical signs of infection in the face of sterile cultures should raise suspicion of Mycobacterium infection among clinicians. While the overall incidence of Mycobacterium infection after breast augmentation is low, it remains an important and often overlooked aetiology for patients with a lack of systemic symptoms and initial sterile cultures.

We used 111 rabbits to study the susceptibility to intravenously injected bacteria of conventional stainless steel plates, and titanium plates of either traditional design or of the PC-FIX concept, that is less traumatic to bone. After plating, the animals were given between 1×10 8 and 2×10 9 colony forming units of Staphylococcus aureus Wood 46 intravenously. Significant differences in infection rates (positive cultures) were found between conventional stainless steel plates (36–67% infected, depending on inoculum size) and titanium PC-FIX plates (6–7% infected). In fact, the infection rate at the PC-FIX plate did not differ from sham operated animals. Since conventionally designed titanium plates had an intermediate infection rate, it appears that design and material both are important for the risk of infection.

Objective The authors describe the first case report of a fungal abscess within a hydroxyapatite orbital implant in a patient who had undergone straightforward secondary hydroxyapatite implant surgery. Design Case report and literature review. Intervention Four months postoperatively after pegging and 17 months after original implant placement, chronic discharge and socket irritation became evident. Recurrent pyogenic granulomas were a problem, but no obvious area of dehiscence was present over the implant. The peg and sleeve were removed 31 months after pegging (44 months after original placement of the implant). The pain and discharge did not resolve, and the entire hydroxyapatite orbital implant was removed 45 months after sleeve placement and 58 months after initial implant placement. The pain and discharge settled rapidly. Main outcome measures Cultures and histopathology. Results Results of bacterial cultures were negative. Results of histopathologic examination of the implant disclosed intertrabecular spaces with multiple clusters of organisms consistent with Aspergillus. Conclusions Persistent orbital discomfort, discharge, and pyogenic granulomas after hydroxyapatite implantation should cause concern regarding potential implant infection. The authors have now shown that this implant infection could be bacterial or fungal in nature. This is essentially a new form of orbital Aspergillus, that of a chronic infection limited to a hydroxyapatite implant.

Objective Prior studies of hydroxyapatite orbital implant complications have primarily focused on complications of the implant itself with only occasional mention of the complications associated with the peg system. This in part may be because of a low rate of pegging and, thus, a small sample size to evaluate. Therefore, a full range of complications that can occur with pegging has not been presented. The objective of this study was to determine the complications associated with pegging and to discuss ways to manage them. Design Retrospective, noncomparative case series. Participants/intervention The authors analyzed all of the complications associated with pegging 165 of a possible 275 hydroxyapatite implants implanted by 2 surgeons over 7 years. Main outcome measures The following data were recorded: type of surgery performed, size of implant used, type of hydroxyapatite used, peg system used, time of pegging, follow-up duration, problems encountered, and treatment. Results Sixty-two (37.5%) of the 165 patients who had pegged implants were found to have problems with their pegs. Twenty-one (33.8%) of the 62 patients with peg problems had more than 1 peg-related problem. Complications associated with pegging included discharge (37%; 23 of 62), pyogenic granulomas (30.6%; 19 of 62), peg falling out (29%; 18 of 62), poor transfer of movement (11.2%; 7 of 62), clicking (11.2%; 7 of 62), conjunctiva overgrowing peg (4.8%; 3 of 62), poor-fitting sleeve (4.8%; 3 of 62), part of sleeve shaft visible (4.8%; 3 of 62), peg drilled on an angle (4.8%; 3 of 62), hydroxyapatite visible around peg hole (3.2%; 2 of 62), peg drilled off-center (3.2%; 2 of 62), popping peg (3.2%; 2 of 62), and excess movement of peg (3.2%; 2 of 62). The most serious complication occurring in two individuals (3.2%) was implant infection requiring implant removal. Conclusion There are several potential complications that can occur after pegging the hydroxyapatite implant. These problems are generally of a minor nature but often require additional patient visits that would not ordinarily have been required if the peg was not in place. The most serious peg problem is implant infection, which may necessitate implant removal. These potential peg problems should be reviewed with the patient before the procedure is performed.

Small numbers of organisms can cause orthopaedic implant infections, which give rise to a considerable degree of morbidity and also mortality. The periprosthetic infection rates have been shown to correlate with the number of airborne bacteria within 30 cm of the wound. This is influenced by factors such as the number of operating theatre personnel, their clothing and the type of ventilation system used. Guidance on routine bacteriological monitoring of ultraclean air theatres, based on the Department of Health document Health Technical Memorandum 2025, is discussed. Factors important in minimizing the number of postoperative implant infections such as the use of ultraclean air, ultraviolet radiation, different types of surgical clothing, prophylactic antibiotics and host-related factors are also discussed. The importance of proper scientific investigation into the effectiveness of practical preventative measures in the operating room is emphasized.

Purpose: The authors describe the rare condition of an abscess within a hydroxyapatite orbital implant in two patients who had undergone seemingly uncomplicated enucleation and orbital implant surgery. Methods: In the first patient, 14 weeks postoperatively, a chronic discharge developed and the socket became uncomfortable. A pyogenic granuloma was present, occurring over an area of dehiscence. The hydroxyapatite orbital implant was removed 10 months postoperatively. In the second patient, moderate orbital discomfort was noted during the first week postoperatively along with a temporal shift of the implant. The discomfort persisted, and 1 week later a discharge began. The implant was removed 9 weeks after implantation. At the time of surgery, an unsuspected pyogenic granuloma was found in the medial conjunctival fornix overlying a small area of implant dehiscence. Results: Conjunctival and implant cultures grew Staphylococcus aureus in our first patient, whereas coagulase-negative staphylococci were cultured from the conjunctiva and implant in our second patient. Results of histopathologic examination of both implants disclosed an abscess cavity containing clusters of gram-positive cocci. Conclusion: Persistent orbital discomfort, discharge, and the development of a pyogenic granuloma after hydroxyapatite implant should warn the ophthalmic surgeon of potential implant infection.

Increasingly, spasticity is managed with surgically implanted Intrathecal Baclofen pumps. Intrathecal Baclofen pump revision surgery unrelated to programmable pump end-of-life is not uncommon, requiring special attention during pre-, intra-, and postoperative management. We aimed to identify and describe complications of Intrathecal Baclofen pump as well as to report avoidance and management of complications. Methods and Materials. Through 2002–2006, at the department of neurosurgery, Henry Ford and Oakwood Health Systems, Intrathecal Baclofen pumps were implanted in 44 patients: 24 children versus 20 adults; 30 “primary-implant-patients”; 14 “revision-only patients”. We evaluated reasons for revision surgeries and diagnostic workup requirements. Results. Eight primary-implant-patients required 14 revisions and 7 of revision-only patients needed 13 procedures. Seven patients with slowly increasing baclofen-resistant spasticity had either (i) unsuspected pump-catheter connector defects, (ii) an X-ray-documented pump-catheter connector defect, (iii) X-ray-demonstrated fractured catheter with intrathecal fragment. Implant infections occurred in 4 cases. Scintigraphy revealed occult CSF leakage N = 1 and intrinsic pump failure N = 1. Conclusion. Intrathecal Baclofen pumps, although very gratifying, have a high, technique-related complication incidence during implant life. Meticulous technique, high clinical suspicion, appropriate workup, and timely surgical management can reduce surgical complications of Intrathecal Baclofen pump implantation.

Late hematogenous infection of previously asymptomatic orthopedic implants is extremely rare and usually associated with total joint replacements, such as those of the hip or knee. We present the case of an otherwise healthy female who developed a deep space infection 18 months after a first metatarsophalangeal joint implant arthroplasty. The patient presented with pain and swelling at the site, and over the course of several days developed fever and tachycardia and leukocytosis. Cultures of the surrounding soft tissues and the implant grew Streptococcus pneumoniae. The patient reported a 1- to 2-week history of symptoms consistent with an upper respiratory tract infection and it is believed that this distant focus of infection was the probable source of late hematogenous seeding of the first metatarsophalangeal joint implant.

A silicone scaphoid implant was developed in 1967 to help improve the results of simple resection arthroplasty in the treatment of arthritic changes associated with advanced scaphoid disease. Patients who had scaphoid implant surgery since 1967 were studied. Preoperative and postoperative roentgenograms, charts, surgical pathology, and clinical evaluations were reviewed. A total of 55 cases of scaphoid implant arthroplasty were evaluated. A classification system was developed based on progressive severity, and treatment recommendations were developed for each stage of disease progression. Cystic and degenerative changes in contiguous carpal bones were evaluated. No evidence of cystic change could be found in 37 wrists, minimal changes were found in 9, moderate changes in 5, and severe changes in 4. There were no implant infections or fractures. Implant rotation occurred in two cases. Functional use of the hand with decreased pain was observed. It is important to detect and treat carpal instability, which may be associated with scaphoid disease. Cystic formation can be minimized by avoiding oversized implants, treating the associated carpal instability, bone-grafting preexisting cysts, and avoiding Kirschner wire fixation. By following treatment protocols as established in the classification system, the scaphoid implant can be successfully used in the management of scaphoid pathology