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The definition criteria and clinical characteristics of implant-associated infection (IAI) caused by Cutibacterium (formerly Propionibacterium) spp. are poorly known. We analyzed microbiologically proven Cutibacterium orthopedic IAI in a prospective cohort. Patients with periprosthetic joint infections (PJI) and fixation device-associated infections (FDAI) caused by Cutibacterium spp. were prospectively included. IAI was defined by significant growth of Cutibacterium spp. and presence of at least one non-microbiological criterion for infection. The McNemar's chi-squared or binomial test was used to compare the performance of diagnostic tests. Of 121 patients with Cutibacterium IAI, 62 patients (51%) had PJI and 59 (49%) had FDAI. 109 infections (90%) were caused by C. acnes and 12 (10%) by C. avidum. The median time from implantation until diagnosis of infection was 15.7 months (interquartile range, 5-46.5 months). Clinical local signs were present in 30 patients (28%) and radiological implant loosening in 64 patients (63%). Culture sensitivity of sonication fluid was 84%, of peri-implant tissue 84% and of synovial or peri-implant fluid 56% after 14 days of incubation. Cutibacterium IAI was diagnosed late in the disease course and presented with subtle signs. Prolonged culture incubation and implant sonication improved the poor performance of conventional microbiological tests. Due to lack of reliable diagnostic tests, Cutibacterium remains difficult to detect making the diagnosis challenging.

Objectives The present study aimed to evaluate the status and trends of robotic orthopedic surgery in a clinical setting using bibliometrics. Methods All relevant publications on the clinical use of robotic surgery in orthopedics were searched from the Web of Science database. Subsequently, data were analyzed using bibliometrics. Visualizing data of bibliographic coupling, co-citation, and co-occurrence analysis were performed using VOSviewer. Results In total, 224 clinical studies met the included standards between 2000 to 2019. Global publications presented an increasing annual trend, with the United States found to have the largest number of publications and robotic companies active in the field ( n  = 99), followed by China ( n  = 38), and the United Kingdom ( n  = 27). The institution with the most contributions was the Beijing Jishuitan Hospital in China ( n  = 15). The most productive scholars were Tian Wei and Mont Michael A, with 14 publications each. The top 30 most cited papers list showed 29 publications to be cited on more than 40 occassions. The journal with the most related and influential publications on robotic orthopedic surgery was the Journal of Arthroplasty. Fourteen types of robots were used, with the majority applied in knee and spinal surgery. MAKO was the most widely used robot in hip and knee surgery and Mazor in spinal surgery. Most studies were small sample populations of low-quality in this field. The top 20 most frequently used keywords were identified from 950 author keywords. Research on orthopedic robots were classified into two clusters by co-occurrence networks: spinal-related robotic surgery and joint-related robotic surgery. Conclusions The present bibliometric study summarizes the clinical research of orthopedic robots on study type, sample size, type of surgery, robot information, surgical site, most popular keywords, most cited papers, journals, authors, institutions, and countries. These findings may assist the scholars better understand the current status and research trends to guide future practice and directions.

IntroductionNew app-based programs for postoperative rehabilitation have been developed, but no long-term study has been published to date. Thus, a prospective randomized control trial with 2-year follow-up was performed to evaluate the effectiveness of app-based rehabilitation (GenuSport) compared to a control group after total knee arthroplasty (TKA).MethodsBetween April and October 2016, 60 patients were enrolled in the study. Twenty-five patients were lost to follow-up, leaving 35 patients undergoing TKA for inclusion. In this group, twenty patients received app-based exercise program and 15 were randomized to the control group. The mean age was 64.37 ± 9.32 years with a mean follow-up of 23.51 ± 1.63 months. Patients in the app group underwent an app-based knee training starting on the day of surgery; whereas, patients in the control group underwent regular physiotherapy. Functional outcome scores using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) and VAS of pain were analyzed.ResultsIn the short term, significant differences between the app group and control group in time of 10-m walk (19.66 ± 7.80 vs. 27.08 ± 15.46 s; p = 0.029), VAS pain at rest and activity (2.65 ± 0.82 vs. 3.57 ± 1.58, respectively 4.03 ± 1.26 vs. 5.05 ± 1.21; p < 0.05) were observed. In the long term, a variety of different tendencies was found, highest in KSS Function with 76.32 ± 16.49 (app group) vs. 67.67 ± 16.57 (control group) (p = 0.130). Additionally, patients in the app group required less painkillers (10.0% vs. 26.7%) and more likely to participate in sports (65.0% vs. 53.3%).ConclusionsAn app-based knee trainer is a promising tool in improving functional outcomes such as KSS function score and VAS after TKA.Level of evidenceLevel II, prospective randomized control trial.

PurposeWe investigated the value of preoperative pathogen detection and evaluated its concordance with intraoperative cultures in patients with culture-positive periprosthetic joint infection (PJI).MethodsCulture-positive PJI episodes with available preoperative (synovial fluid) and intraoperative cultures (periprosthetic tissue, synovial or sonication fluid) were analyzed. The pathogen detection rate in preoperative and intraoperative cultures was compared using Fisher’s exact test and their concordance was calculated.ResultsAmong 167 included PJI episodes, 150 were monomicrobial with coagulase-negative staphylococci (n = 55, 37%), S. aureus (n = 34, 23%), and streptococci (n = 21, 14%) being the most common pathogens. Seventeen episodes (10%) were polymicrobial infections. The pathogen(s) grew in preoperative culture in 110 and in intraoperative cultures in 153 episodes (66% vs. 92%, p < 0.001). The pathogen detection rate was lower in preoperative compared to intraoperative cultures for low-virulent pathogens (40% vs. 94%, p < 0.001), polymicrobial infections (59% vs. 100%, p = 0.007), and in delayed and late PJI (63% vs. 94%, and 66% vs. 91%, respectively, p < 0.001). Full concordance of preoperative and intraoperative cultures was found in 87 episodes (52%). The pathogen was detected solely preoperatively in 14 episodes (8%) and solely intraoperatively in 57 cases (34%); an additional pathogen was found in 3 episodes (2%) preoperatively and in 6 episodes (4%) intraoperatively.ConclusionThe concordance of preoperative and intraoperative cultures was poor (52%). The sole or an additional pathogen was found exclusively in intraoperative cultures in 38% of PJI episodes, hence preoperative synovial fluid cultures are considered unreliable for pathogen detection in PJI.

Diseases that jeopardize the musculoskeletal system and cause chronic impairment are prevalent throughout the Western world. In Germany alone, ~1.8 million patients suffer from these diseases annually, and medical expenses have been reported to reach 34.2bn Euros. Although musculoskeletal disorders are seldom fatal, they compromise quality of life and diminish functional capacity. For example, musculoskeletal disorders incur an annual loss of over 0.8 million workforce years to the German economy. Among these diseases, traumatic skeletal muscle injuries are especially problematic because they can occur owing to a variety of causes and are very challenging to treat. In contrast to chronic muscle diseases such as dystrophy, sarcopenia, or cachexia, traumatic muscle injuries inflict damage to localized muscle groups. Although minor muscle trauma heals without severe consequences, no reliable clinical strategy exists to prevent excessive fibrosis or fatty degeneration, both of which occur after severe traumatic injury and contribute to muscle degeneration and dysfunction. Of the many proposed strategies, cell‐based approaches have shown the most promising results in numerous pre‐clinical studies and have demonstrated success in the handful of clinical trials performed so far. A number of myogenic and non‐myogenic cell types benefit muscle healing, either by directly participating in new tissue formation or by stimulating the endogenous processes of muscle repair. These cell types operate via distinct modes of action, and they demonstrate varying levels of feasibility for muscle regeneration depending, to an extent, on the muscle injury model used. While in some models the injury naturally resolves over time, other models have been developed to recapitulate the peculiarities of real‐life injuries and therefore mimic the structural and functional impairment observed in humans. Existing limitations of cell therapy approaches include issues related to autologous harvesting, expansion and sorting protocols, optimal dosage, and viability after transplantation. Several clinical trials have been performed to treat skeletal muscle injuries using myogenic progenitor cells or multipotent stromal cells, with promising outcomes. Recent improvements in our understanding of cell behaviour and the mechanistic basis for their modes of action have led to a new paradigm in cell therapies where physical, chemical, and signalling cues presented through biomaterials can instruct cells and enhance their regenerative capacity. Altogether, these studies and experiences provide a positive outlook on future opportunities towards innovative cell‐based solutions for treating traumatic muscle injuries—a so far unmet clinical need.

Purpose This prospective cohort study aimed to examine objective and subjective parameters in patients who underwent total knee replacement (TKR) to assess from when on driving a car can be deemed safe again. Methods Thirty patients (16 women, 14 men, age 66 ± 11 years) who received TKR of the right knee and 45 healthy controls (26 women, 19 men, age 32 ± 9 years) were asked to perform an emergency braking manoeuvre using a driving simulator. Brake pedal force (BPF), neuronal reaction time (NRT), brake reaction time (BRT), and subjective parameters (pain, subjective driving ability) were measured preoperatively as well as 5 days, 3–4, and 6 weeks after TKR. Results Preoperative NRT was 506 ± 162 ms, BRT 985 ± 356 ms, and BPF 614 ± 292 N. NRT increased to 561 ± 218 ms, BRT to 1091 ± 404 ms and BPF decreased to 411 ± 191 N 5 days after TKR. Three weeks after surgery, NRT was 581 ± 164 ms and BRT 1013 ± 260 ms, while BPF increased to 555 ± 200 N. Only BPF showed significant differences ( p  < 0.01). In week 6, all parameters were restored to baseline levels; patients showed significant pain decrease and evaluated their driving ability as “good” again. Conclusion BPF was the only parameter displaying a significant postoperative decrease. However, preoperative patients’ baseline levels and subjective confidence in driving ability were only reached 6 weeks after the operation. These results indicate that a minimum waiting period of 6 weeks should be considered before patients can safely participate in road traffic at their individual preoperative safety level again. Level of evidence II.

Background Treatment of enterococcal periprosthetic joint infections (PJI) is challenging due to non-standardized management strategies and lack of biofilm-active antibiotics. The optimal surgical and antimicrobial therapy are unknown. Therefore, we evaluated characteristics and outcome of enterococcal PJI. Methods Consecutive patients with enterococcal PJI from two specialized orthopedic institutions were retrospectively analyzed. Both institutions are following the same diagnostic and treatment concepts. The probability of relapse-free survival was estimated using Kaplan-Meier survival curves and compared by log-rank test. Treatment success was defined by absence of relapse or persistence of PJI due to enterococci or death related to enterococcal PJI. Clinical success was defined by the infection-free status, no subsequent surgical intervention for persistent or perioperative infection after re-implantation and no PJI-related death within 3 months. Results Included were 75 enterococcal PJI episodes, involving 41 hip, 30 knee, 2 elbow and 2 shoulder prostheses. PJI occurred postoperatively in 61 episodes (81%), hematogenously in 13 (17%) and by contiguous spread in one. E. faecalis grew in 64 episodes, E. faecium in 10 and E. casseliflavus in one episode(s). Additional microorganism(s) were isolated in 38 patients (51%). Enterococci were susceptible to vancomycin in 73 of 75 isolates (97%), to daptomycin in all 75 isolates, and to fosfomycin in 21 of 22 isolates (96%). The outcome data was available for 66 patients (88%). The treatment success after 3 years was 83.7% (95% confidence interval [CI]; 76.1–96.7%) and the clinical success was 67.5% (95% CI; 57.3–80.8%). In 11 patients (17%), a new PJI episode caused by a different pathogen occurred. All failures occurred within 3 years after surgery. Conclusion About half of enterococcal PJI were polymicrobial infections. The treatment success was high (84%). All treatment failures occurred within the first 3 years after revision surgery. Interestingly, 17% of patients experienced a new PJI caused by another pathogen at a later stage. Trial registration The study was retrospectively registered with the public clinical trial identification NCT0253022 at https://www.clinicaltrials.gov on 15 July 2015.

Background In spine surgery, surgical site infection (SSI) is one of the main perioperative complications and is associated with a higher patient morbidity and longer patient hospitalization. Most factors associated with SSI are connected with asepsis during the surgical procedure and thus with contamination of implants and instruments used which can be caused by pre- and intraoperative factors. In this systematic review we evaluate the current literature on these causes and discuss possible solutions to avoid implant and instrument contamination. Methods A systematic literature search of PubMed addressing implant, instrument and tray contamination in orthopaedic and spinal surgery from 2001 to 2019 was conducted following the PRISMA guidelines. All studies regarding implant and instrument contamination in orthopaedic surgery published in English language were included. Results Thirty-five studies were eligible for inclusion and were divided into pre- and intraoperative causes for implant and instrument contamination. Multiple studies showed that reprocessing of medical devices for surgery may be insufficient and lead to surgical site contamination. Regarding intraoperative causes, contamination of gloves and gowns as well as contamination via air are the most striking factors contributing to microbial contamination. Conclusions Our systematic literature review shows that multiple factors can lead to instrument or implant contamination. Intraoperative causes of contamination can be avoided by implementing behavior such as changing gloves right before handling an implant and reducing the instruments’ intraoperative exposure to air. In avoidance of preoperative contamination, there still is a lack of convincing evidence for the use of single-use implants in orthopaedic surgery.

Background An effective immune system, especially during the inflammatory phase, putatively influences the quality and likelihood of bone healing. If and how this is reflected within the initial fracture hematoma is unclear. Questions/purposes We therefore asked the following questions: (1) Does the local expression in fracture hematoma of genes involved in adaptation to hypoxia, migration, angiogenesis, and osteogenesis vary as compared to the peripheral blood? (2) Do these changes occur time dependently? (3) Is the gene expression during fracture hematoma formation altered by irradiation? Methods Cells from fracture hematoma of 20 patients and hematomas formed in 40 patients after THA (20 without and 20 with preoperative radiation) were isolated and RNA was extracted to analyze the influence of oxygen deprivation during fracture healing on mRNA expression of genes (HIF1A, LDHA, and PGK1) involved in immunoregulation (IL6, IL8, CXCR4), angiogenesis (VEGF, IL8), and osteogenesis (SPP1, RUNX2) by quantitative PCR. Results We observed locally increased LDHA gene expression in fracture hematoma cells (6–72 h post fracture) reflecting the adaptation to hypoxia. IL6, IL8, and VEGF upregulation indicated hypoxia-mediated inflammation and angiogenesis; increased CXCR4 expression reflected immigration of immune cells. Osteogenic differentiation was reflected in the increased expression of the SPP1 and RUNX2 genes. The increased expression of the LDHA, VEGF, IL8, SPP1 and RUNX2 genes occurred time dependently. Irradiation suppressed HIF1A, IL6, IL8, CXCR4, and RUNX2 gene expression. Conclusions Our data suggest cells in the fracture hematoma (1) adapt to hypoxia and (2) promote inflammation in fracture healing at the mRNA level, indicating early involvement of the immune system. Clinical Relevance The initial fracture hematoma is important for the onset of angiogenesis, chemotaxis, and osteogenesis.

Purpose The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis. Methods In this case–control study, n  = 36 patients with a preoperative mechanical tibiofemoral angle (mTFA) ≥ 15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA < 15°) of n  = 60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]). Results The degree of correcting the mTFA by TKA significantly correlated with the postoperative FFI ( R  = 0.95, p  < 0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-off value of 16.5° [AUC 0.912 (0.85–0.975 95% CI), sensitivity = 0.8, specificity = 0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10–127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong significant correlation with the FFI ( R  = 0.74, p  < 0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint. Conclusions In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stiff subtalar joint. Level of evidence III.