Introduction: Anemia and blood transfusions are known risk factors for periprosthetic joint infection (PJI) in total joint arthroplasty (TJA) patients. Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion needs. This study aims to explore whether perioperative TXA administration, both intravenously (IV) and topically intra-articularly, is associated with a decreased incidence of PJI in TJA patients. Methods: Data from 8042 patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from January 2009 to December 2020 were collected. The primary outcome was the occurrence of PJI within one year post-surgery. Secondary outcomes included blood transfusion rates, length of hospital stay (LOS), venous thromboembolism (VTE), and 90-day readmission. Subgroup analysis examined the odds ratio of PJI in patients receiving IV and topical TXA in both THA and TKA. Results: Patients receiving TXA had a lower PJI rate (1.1% vs. 2.1%, p < 0.001), fewer blood transfusions (14.4% vs. 22.7%, p < 0.001), and shorter LOS (5.6 ± 1.6 vs. 6.5 ± 2.5, p < 0.001). There were no significant differences in VTE or 90-day readmission rates between the groups. Perioperative TXA administration was associated with a lower risk of PJI in multivariate analysis (OR 0.54, 95% CI 0.36-0.80, p = 0.002) and propensity score weighting. Subgroup analysis showed that both IV and topical TXA administration resulted in decreased PJI rates, particularly in primary TKA. Conclusion: Administration of TXA during primary THA and TKA is associated with a reduced risk of periprosthetic joint infection.

Introduction. Treatment of orthopedic infection requires a multimodal approach, including surgical debridement, adequate wound drainage, local and systemic antibiotic therapy. Local therapy is provided by depot matrices, mostly based on polymethyl methacrylate (PMMA). PMMA, due to the release of up to 10% of the impregnated antibiotic from its total loaded amount, cannot be considered an optimal depot system. Methods. Samples of polymer hydrogel and PMMA with a volume of 4 cm3, impregnated with vancomycin, rifampicin and cefazolin in various concentrations, were placed in phosphate-buffered saline and incubated at 37 °C. On days 1, 3, 7, 14, 21 and 28, the medium was completely replaced. The concentration of drugs and their release profiles were evaluated using spectrophotometry. 5 parallel studies were performed. Data were processed using Me and 95% CI.
Results. For hydrogel samples, the drug release was more than 70% of its total amount, in contrast to PMMA (less than 10%). Burst release was observed in the hydrogels, with up to 80% of the amount released in the first 5 days and exceeding the minimum inhibitory concentrations during the entire observation period. The concentrations released by the hydrogel were on average 7 times higher on day 1, 15 times higher on day 3, 6.6 times higher on day 7, and 3 times or more on subsequent days of observation. Conclusion: The release of antibiotics due to the diffusion of particles is an important advantage of hydrogels compared to PMMA, which potential is limited by surface depletion.

Introduction: the incidence of infectious complications after orthopedic surgery is increasing every year. Microbial pathogens form three-dimensional biofilms, only possible to be eradicated by lesion sanation and antibiotic therapy, local and/or systemic. Existing depot systems based on polymethyl methacrylate (PMMA) have several disadvantages. Methods: a comparative analysis of the antimicrobial activity of 13x8 mm cylinder samples based on biodegradable polymer hydrogel and PMMA was carried out against MSSA, MRSA, MSSE, MRSE and A. baumannii, sensitive to the tested antibiotics with different physicochemical properties. The bactericidal activity of microbe-antibiotic pairs: MSSA-gentamicin, MSSE-cefazolin, MRSA and MRSE-vancomycin, A. baumannii-tobramycin - was studied in 3 parallel studies. The study procedure was based at the disk diffusion microbiological method. The duration of the study was 7 days. Data was processed using Me and 95% CI, Mann-Whitney and Wilcoxon tests. Results: the antimicrobial effect of the polymer hydrogel against the leading pathogens of orthopedic infections from the first day of incubation was significantly (p = 0.002) higher than the activity of PMMA. The PMMA bactericidal effect was short-term (up to 3 days) with a significant (p = 0.042) decrease in activity on the 2nd day of cultivation. The inhibition zone around the hydrogel throughout the study (as a result of controlled diffusion of antibiotics) was reduced by an average of 1-2 mm. Conclusion: Polymer biodegradable hydrogels impregnated with antibiotics have greater antimicrobial potential compared to PMMA.

Introduction:- Chronic osteomyelitis (chronic OM) is one of the oldest known diseases in the field of Orthopedics. Despite the advent of recent technologies and advances in microbiology and surgery, there is no general consensus on a single perfect treatment strategy in the present time. The major concern is the reliable safe eradication method of the residual germs . The desired minimal inhibitory concentrations (MIC) reached with any intravenous antibiotic is used may reach to toxic levels putting the patient's health at risk. Methods:- A prospective study of 20 cases of bone chronic osteomyelitis was performed in our institute with follow up of 1 year. All patients were screened with pertaining hematological, microbiological and radiological investigations. All cases were operated upon with thorough debridement first and then we used dissolvable antibiotic-loaded calcium sulphate hemihydrate (CaSO4.H2O)beads that is known commercially as Stimulan. The patients were given culture sensitive antibiotics for a period of 1 week intravenously and then orally for a period of 2 weeks. Patients were followed up at 1 month, 6 months and 12 months post-operatively. Results: The criterias for chronic OM eradication were clinical, radiological and laboratory. Out of the 20 cases, there was complete eradication in 17 and remaining 3 required other modalities of treatment.Conclusion : The use of Stimulan allows the fast, continuous and prolonged delivery of antibiotics into bone voids after debriding chronic OM properly. Further large scale study is required to propose Stimulan as a single perfect treatment for Chronic Osteomyelitis .

Introduction: This study aims to define a novel MRI sign that could indicate the severity of pyogenic spondylitis, aiding in its early diagnosis and treatment.Method: This retrospective study included 137 patients from 2013 to 2023. Through the analysis of imaging characteristics among all patients, we identified a distinct MRI sign known as the ‘Disc Penetration Sign’ (DP). This sign is defined as an image finding on sagittal MRI depicting the anterior and posterior penetration of an abscess through the intervertebral disc space, affecting both the anterior margin of the vertebrae and the structures within the spinal canal. Observational parameters included WBC, ESR, CRP, hemoglobin, and albumin levels. Documentation of the study included the location and segment of the lesion, presence or absence of spinal cord compression, and paravertebral abscesses.Results: Fifty-six patients presented with the Disc Penetration Sign (DP), and eighty-one did not. The DP group had significantly higher ESR and CRP levels. Additionally, the DP group had significantly lower hemoglobin and serum albumin levels. Imaging results showed no significant differences in affected spinal segments or parts. Patients in the DP group exhibited a higher likelihood of developing paravertebral abscesses compared to those in the non-DP group and also exhibited a higher incidence of spinal cord compression.Conclusions: The study suggests that the Disc Penetration Sign in pyogenic spondylitis patients correlates with more severe inflammation, higher incidence of paraspinal abscesses, and potentially poorer prognosis.

Introduction: Diagnosing fracture related infection (FRI) requires either purulent discharge from wound or positive culture reports which take time. This necessitates the need for accurate and rapid diagnosis. Taking forward a pilot study on biomarkers for diagnosing FRI, this study was conducted to determine the accuracy of Alpha Defensin (AD) for the diagnosis of FRI in open fractures.Methods: Wound fluid levels of alpha-defensin (AD) were evaluated on post-operative day 2 of patients with open fractures via sandwich ELISA, and patients were followed up for three weeks. Patients were categorized as cases (FRI) or controls (no FRI), based on the consensus definition of FRI. Univariate and multivariable logistic regression analysis, along with receiver operating characteristic (ROC) analysis was performed. Results: 153 patients with average age of 36.3 (SD ± 14.6) years were included. AD levels showed a significant (P=0.001), 2.1-fold elevation in cases (n = 63, Mean = 28.8 µg/ml) as compared to controls (n = 83, mean = 13.5 µg/ml). The area under the curve for this estimate was 0.71. As per Youden’s index, an AD value cut-off value of a value of 7.85 µg/ml had a sensitivity of 71.4% and specificity of 68.7%. Multivariate logistic regression revealed AD and Gustilo Anderson grade as independent predictors of FRI. Conclusion: Wound AD levels are significantly elevated in patients with open fracture who develop FRI. This can be used as a diagnostic tool for early diagnosis when overt clinical symptoms haven’t developed.

Introduction: Chronic periprosthetic hip and knee infection occurring simultaneously poses a rare and challenging complication following lower limb surgery. The gold standard treatment for septic revision surgery typically involves the implantation of a bone cement spacer loaded with antibiotics. However, cases necessitating a two-stage revision with a total femur (TF) replacement present ongoing challenges for orthopedic surgeons. We present a case study detailing the use of a custom constructed modular TF antibiotic spacer for the treatment of simultaneous periprosthetic hip and knee joint infections. Case presentation: A 62-year-old female patient was admitted to our hospital with left hip pain and a fistula near the postoperative scar. She had a history of multiple revision surgeries for periprosthetic hip infection, long-term antibiotic treatment, and distal femur periprosthetic fracture stabilization. Clinical examinations and microbiological analysis confirmed Staphylococcus aureus infection. The treatment involved a two-stage revision surgery, with the first stage involving placement of a modular TF cement spacer and the second stage TF megaprosthesis implantation. The spacer, constructed using revision cement implant with calcar and a Kuntscher nail, was coated with Vancomycin and Gentamicin-loaded cement. Postoperatively, intravenous antibiotics were administered for eight weeks, leading to the normalization of clinical and laboratory parameters. In second stage TF megaprosthesis was successfully implanted, with intraoperatively sampled tissue cultures proving sterile. Conclusion: The use of a custom-made modular TF antibiotic-loaded cement spacer in our case provided satisfactory results as part of a two-stage revision surgery, allowing for early weight-bearing and hip mobility prior to total femur replacement.

Introduction : Antibiotics are a key point in the management of periprosthetic joint infection. Orthopedics surgeons tend to have excessive prescription of antibiotics to ensure a rapid result. Methods : We conducted a web-based survey to evaluate the orthopedic surgeons’ knowledge and attitudes regarding the prescription of antibiotics in managing periprosthetic joint infection using a serie of 26 questions. Results : A total of 60 surgeons participated in this survey. Most doctors (90%) work at a teaching hospital. 45% prescribe antibiotics to old patients over 65 years old who underwent hip arthroplasty over 43.3% for knee arthroplasty. Surgeons working in the private sector stated that they prescribed postoperative antibiotics for hip and knee arthroplasties. Surgeons stated they prescribed as a first line antibiotics the following molecules : amoxicillinclavulanicacid-fluoroquinolone (30%), Vancomycin-Piperacillintazobactam (23.4%), amoxicillinclavulanicacid-gentamycin (21.7%), Ofloxacin-rifampicin (10%). All surgeons performed bacteriological samples. Only 83.3% adapted the treatment according to the results. 63.3% often asked an expert in infectious diseases. Surgeons stated that the main difficulty was the delay in bacteriological sampling in 68.3%, lack of national recommendations regarding antibiotics in 63.3%, availability of oral treatment in 55%, treatment shortage in hospitals in 51.7%, allergies in 28.3%. Only 36.7% used vancomycin powder mostly in arthroplasty and revision. Conclusion : Emerging antimicrobial resistance and the lack of new molecules represents a real threat to clinicians added high cost due to intravenous treatment. Prevention remains the key. Optimal management includes a collaboration between an infectologist and surgeon.

Purpose- There is scarcity of evidence on correlation of tuberculosis of lumbar spine with respect to spinopelvic harmony. The current study aims to find the association between functional outcomes & spinopelvic parameters in lumbar spine tuberculosis treatment.
Methods- 47 patients with active tuberculosis confined to Lumbar spine were prospectively analysed and divided in to two groups according to mode of intervention. Group A included 26 operatively managed patients and group B had 21 conservatively managed cases. Functional parameters comprising ODI and VAS along with spinopelvic radiological parameters (PI, PT, SS, LL, PI-LL, SVA) in both groups were analysed at 0 and 1 year of follow-up.
Result- Both the groups showed significant improvement from initial presentation to final follow-up in ODI (Gr-A: 85.4±12.1 to 12.3±3.2, p=0.02; Gr-B: 82.5±10.06 to 36.8±11.9, p=0.04) and VAS (Gr-A: 8.1±1.2 to 1.4±0.9, p=0.02; Gr-B: 8.5±0.09 to 3.5±1.1, p=0.02). Statistically significant (p<0.05) difference was observed in both functional outcome parameters between the two groups in successive follow-ups, compared to nonsignificant difference (p>0.05) at presentation. Better improvements of spinopelvic parameters of PT, SS, LL, PI-LL were observed in surgical group and in both groups difference of these parameters correlated with differences of functional outcome parameters, though PI showed no correlation.
Conclusion- The spinopelvic parameters played significant role in functional outcome. There is better functional outcome when LL is adequately restored. Surgical correction offered betterment of spinopelvic parameters like PT, SS & SVA, which in turn leads to improvement in functional outcome.

Early diagnosis, early surgical intervention, and intensive treatment is important for necrotizing soft tissue infections. The other hand, severe cellulitis does not require surgical intervention. If surgical intervention were performed in all cases of severe cellulitis, this would lead to progression of skin necrosis and a decrease in the effectiveness of antibiotics, delaying healing. Therefore, we will discuss the differences between necrotizing soft tissue infection and severe cellulitis in cases with a score of 6 or higher.
This time, we targeted 18 cases of soft tissue infections treated at our department from 2014 to 2023 with an LRINEC score of 6 or higher. There were 13 male cases and 5 female cases, with an average age of 61.6 years (42 to 91 years). There were 12 cases of necrotizing soft tissue infection and 6 cases of severe cellulitis. Items to be considered include mean blood pressure, pulse rate, respiratory rate, WBC, CRP, PCT, Cr, BUN, SOFA score, acute phase DIC score, pH, Lac, use of vasopressors, rapid streptococcal test, computer tomography (CT), Echo findings and finger tests were reviewed.
As a result of the study, significant differences were observed in Cr (P=0.017), LRINEC score (P=0.00), gas image on CT, fluid accumulation on the fascia, and finger test.
In patients with an LRINEC score of 6 or higher, a high LRINEC score and worsening renal function are findings that suggest necrotizing soft tissue infection, and findings such as CT and echocardiography and finger tests are considered useful for differential diagnosis.

Introduction: One third of World population is thought to be infected with Tuberculosis and one fourth of them live in India. Most of the spinal infection presents with para vertebral abscess and some of them become too large due to prevailing poor socio-economic and health conditions in India. Materials: This is a study of 22 cases of percutaneous negative suction drainage of large psoas abscesses. There were 10 males and 12 females with age ranging from 28 years to 70 years. The study was performed from July 2005 to June 2022. Method: A 16 gauge negative close wound suction drain is introduced in the abscess as an OPD procedure under sedation and aseptic conditions. The drain is kept until the whole abscess is drained out. The amount of aspirate varies from 800 ml to 1400 ml. Aspirate was investigated for TB PCR and TB culture and sensitivity. None of the patient required surgical drainage. One patient developed sinus at drain site which healed in due course of time. All patients were given anti-tubercular treatment. Discussion: This procedure does not have inherent risks of CT radiation, anesthesia and surgery. The anti-tubercular treatment becomes more effective after drainage of abscess. This procedure ultimately reduces the morbidity and mortality of the patients. Conclusion: Percutaneous negative suction drainage is an efficient, easy, safe, effective and cheap procedure for drainage of large psoas abscess and can be done as a day care procedure under sedation and local anesthesia.