Posted on March 16, 2017
By Ollie Cowan, Champion
Contractors could charge as much as £40 million to dredge the Marine Lake of a huge build up of rubbish.
Prams, trolleys and bikes are all known to be littering the Marine Lake bed on the promenade – a regularly recurring act of wanton vandalism – and the build up of rubbish is having a suspected detrimental affect on the local wildlife.
Councillors are now set to discuss a new report into what it would take to dredge the Marine Lake, with one option leaving them with a bill of anywhere between £0 million and £40 million.
A Sefton Council report to the Southport Area Committee, said: “To dredge the lake would have a significant effect on the lake users, the sailing program would be significantly disrupted affecting club membership.
“Contact has been made with one of the UKs most experienced aquatic management companies in order to establish the costs of dredging.
“There would be two options for the dredging process, either hydraulic dredging to local land or mechanical dredging with the material being taken away.
“The estimated cost for hydraulic dredging is £4.5 million; this would require the silt to be pumped onto local land. Due to the makeup of the silt and surrounding land this method would not be possible, therefore the alternative option is mechanical dredging.
“Mechanical dredging is more expensive as it requires the silt to be taken away in order for it to be disposed.
“The estimate cost for this process is circa £20 – £40 million. As a guide its costs around £66.00 per tonne of material to take away, this is not including removing the silt, plant and labour.
“The lake is filled and emptied via a sluice gate co-ordinated around high tides. This means when the lake is filled with water new sediment is brought in, the reverse happens when the lake is emptied.”
Cllr Sue Mcguire, leader of the Lib Dems, said: “This is absolutely ridiculous. I’m shocked at the brevity and lack of detail in the report.
“The cost quoted of between £20 to £40 million is ludicrous; it includes no breakdown of costs no information on the length of time it would take, the amount of silt present or the equipment that would be required.
“This report cannot be considered a serious proposal rather an excuse by Sefton Council to kick this idea into the long grass.
“There are many other things that £40 million could be spent on that would be of more benefit to the residents and businesses of Southport.”
Dukes ward councillor David Barton said: “As someone who used to row on the Marine lake during his youth I would suggest a more open dialogue with local stakeholders such as Merchant Taylors’ Schools to best deliver on behalf of the local community.”


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Int J Nanomedicine. 2022 Dec 27;17:6593-6606. doi: 10.2147/IJN.S389194. eCollection 2022.
INTRODUCTION: Micro-sized sponge particulates have attracted extensive attention because of their potential to overcome the intrinsic limitations of conventional monolithic scaffolds in tissue engineering. Bioactive nanocomposite microsponges are regarded as potential bone substitute materials for bone regeneration.
METHODS: Based on a combination of microfluidic emulsion with further freezing and in situ thawing, chitosan (CS)-hydroxyapatite (HAP) microsponges were prepared and characterized in terms of their morphology and elemental distribution using a scanning electron microscope equipped with an X-ray detector. The swelling ratio, porosity, degradability, antibacterial activity, and bioactivity were detected and analyzed. The biological functions of the CS-HAP microsponges were examined to assess the adhesion, proliferation, and differentiation of in vitro co-cultured rat bone marrow mesenchymal stem cells (rBMSCs). Furthermore, the CS-HAP microsponges were used as cell-free scaffolds and implanted into calvarial defects in a rat model to evaluate the in vivo osteogenesis.
RESULTS: The CS-HAP microsponges have a porous structure with high porosity (~76%), good swelling capacity (~1900%), and shape-memory properties. The results of in vitro experiments show that the CS-HAP microsponges achieve good bioactivity and promote osteogenic differentiation of rBMSCs. Furthermore, the CS-HAP microsponges significantly promote bone regeneration in rat calvarial defects.
CONCLUSION: The bioactive CS-HAP microsponges have the potential to be used as bone substitute materials for bone tissue engineering.

domain: chemistry


text:
Travelzoo UK Top 20
June, 2015, will go down as a big month here at Travelzoo. Not only did we unveil the brand-new blog that you’re looking at right now, but we also launched our first ever TV advertising campaign in Europe.
This new ad is built around the concept of the “Travelzoo Feeling” – that feeling you get when all your holiday plans come together perfectly. It’s the moment you feel the sand beneath your feet, take a sip of your first mojito at the poolside bar, or take in the sea views from your upgraded room. It’s your own personal holiday victory dance.
In the case of our characters in the advert, the feeling is so strong that it cannot be contained, and comes out in a spontaneous, unselfconscious explosion of totally joyful silliness. Click below now to see what we mean.
The director of the advert is Remy Cayuela, a young comedy director from Paris with string of awards to his name, most notably last year’s Young Director Award (Music Video) at Cannes Lions.
The voiceover artist is John Lloyd, an award-winning British television producer and writer best known for his work on iconic UK comedy shows such as “Blackadder”, “QI” and “Spitting Image”.
The UK ad will premiere on Sunday, 21 June, during Kevin McCloud’s “Escape to the Wild” series and will also be shown during the premiere of “True Detective” series 2.
Now we want to see your #Travelzoo Feeling
We will be running a competition across social media until the end of July using the hashtag #TravelzooFeeling – submit a photo or video of you that captures your “Travelzoo Feeling”, and the best entry will be awarded any Top 20 deal. for more info.
Mobile Application (TripAdvisor)
Mobile Application (KAYAK Software Corporation)

domain: artistic


text:
I didn't write much short fiction before I attended the Kenyon Review Writers Workshop last summer (which I cannot recommend enough). I took Nancy Zafris' short fiction class after attending her novel workshop the previous summer. She said the short fiction class would help me with line-level things that would be beneficial to my novel-writing. She was right (she always is).
For the first assignment that was given before the workshop, she asked us to write a 300-word story based on a picture of a gel character smashed onto the sidewalk. It was the kid of gel creature that my kids get at fairs or from tickets at Dave and Busters. They end up on my ceiling, and the red ones leave a stain behind - my dining room table was forever marked with a red starfish.
My response to Nancy's request for us to write a 300-word story was that this isn't a thing. That is the length of a cover letter. It is three paragraphs. Stories cannot be 300 words long. I was proven wrong.
That week, I learned how to write tiny stories and how to be incredibly concise in service to a limited word count.
The week-long workshop was generative - we were given a new prompt every day and struggled to write a new story every afternoon (until 1:00 a.m. for me most nights).
In the end, I completed two stories that I loved and had a few that were kind of so-so that I have since abandoned. I left Kenyon sorely wishing I could completely rewrite my one story that had already been accepted for publication, "Hostess of the Dead," which is forever in print as is in Best of Ohio Short Stories: Volume II.
As soon as I got home, I used one of the more complicated prompts to write a story for a local contest. I won some (relatively) good money for it and later received Honorable Mention when I entered that same story in Glimmer Train's March/April 2017 Very Short Fiction contest.
I wrote another story this April that was recently published at Four Ties Lit Review. It's 1200 words, which has become the sweet spot for me with short fiction. You can read it here if you like:
"Creamed Corn and Ninja Stars" at Four Ties Lit Review
What I lacked last summer when the conference was over (and quickly figured out) was a strategy to get the stories published. That's where Nancy and Geeta Kothari helped. They said to put myself on a submission schedule. I should submit two times a week (and it's okay if it is the same story that I submit in the same week). I believe they said to avoid contests, but I think I've heard that from professors also.
If you submit twice a week for a year, you will have submitted about 100 times. Chances are, the stories will be published. This has been true for me and others from that workshop that followed the same strategy. The lovely part is that I have had four stories published in a year and now completely accept the idea that rejection is part of the job. (I honestly did not submit 100 - I got to about 50 including academic papers - and withdrew many of the submissions after the stories were accepted.)
The bottom line is that if we aren't writing, we have nothing to submit. If we aren't submitting, we aren't doing our jobs.
Do you have any tips for finding journals to submit to for short fiction (many journals seem to be closed in the summer) or strategies for publishing short fiction?


Andy Ling from Positive Change Buildings discussed the renovation of a post-war Queenslander using the Living Building Challenge which is widely considered to be the most stringent green building standard in the world. Andy took us through the flower metaphor for the framework and explained its seven performance areas including: site, water, energy, health and happiness, materials, equity and beauty and how these were incorporated into his project.
Deborah Craig of Borgelt & Craig Architects shared personal insight into the question of whether to retain or demolish an old timber cottage when designing a project on an existing house block. Deborah discussed two projects, one in which a building was demolished and the other retained, and talked through the sustainable building approaches that were taken for each.
Paul Worroll presented examples of adaptive re-use and the lessons learnt by Reddog Architects. Paul took us through two innovative residential projects where he encouraged his clients to create outdoor pavillions and living areas rather than incorporate air conditioning.
Thanks go out to all our speakers: Andy Ling, Deborah Craig and Paul Worroll, and sponsors BE Collective, Sneaky Sneaky (formerly Tonic Cafe and Bar), and Verde Design.
Sign up to our e-mail newsletters for information on AGDF’s next Green Speed Learning Forum in 2020.


scheduled hot end internal inspections is limited. Refer to table 2-3 notes. Continued use of leaded aviation gasoline or
jet fuel in excess of 1% of aviation gasoline, may cause failure of the vaporizing tubes and subsequent turbine blade
damage resulting in a safety-of-flight hazard. The continued use of jet fuel contaminated with less than 1% of aviation
gasoline is permissible in these aircraft. If the permissible accumulated operating time is exceeded, a special cleaning
and inspection becomes mandatory. The cleaning and inspection may be delayed for 10 operating hours provided only
recommended fuel is used during the delay. A fuel mixture which contains over 10% leaded gasoline shall be identified
as all-leaded gasoline on DA Form 2408-13, Aircraft Inspection and Maintenance Record.
e. Gasoline containing TCP (Tricresyl Phosphate) in addition to TEL (Tetraethyl Lead) is more detrimental to
combustor parts than gasoline containing TEL only. Deterioration of combustor parts occurs at least twice as fast when
TCP is added to leaded gasoline. Operating time on gasoline with TCP is therefore limited to one-half the time allowed
on leaded gasoline without TCP and shall be clearly indicated in the fueling records. Whenever fuel with TCP is used,
special cleaning and inspection of combustor parts is mandatory.
f. For information concerning the cleaning of combustor parts after the use of emergency fuels, refer to the
applicable maintenance manuals.
g. See footnote in table 2-3 for limitations and precautions with emergency fuel.
Record emergency fuel flight time on DA Form 2408-13 block 17. When DA Form 2408-13 is
removed from the log book, transfer the emergency fuel data to DA Form 2408-15 for the
engine and record both that days flight time on emergency fuel and a total flight time on
2-7. Detection of Leaks.
a. Introduction. Dyed fuel may be used for static leak detection of JP-4 fuel cells and complete fuel systems.
Inflight tests to detect leaks, which cannot be detected by static or engine runup test may be used. However, the use of
inflight tests requires special approval of the maintenance officer.
b. Preparation of Dye Solution. The quantities of liquid dye to be used and the mixing ratios are as specified in
c. Mixing in Servicing Vehicle. The dye can be blended in a refueling vehicle that has been reserved for servicing
dyed fuel. The required quantity of dye should be determined before starting. To insure proper mixing of dye in fuel,
partially fill the trailer to about 10 percent and then add the appropriate amount of dye slowly to the contents of the trailer
while the trailer is filled with . remaining fuel.
d. Static Leak Detection in Fuel Cells. Use a diagram of the leaking fuel cell which shows al' connections.
(1) Transfer the fuel into another cell or defuel as necessary. Pour the liquid dye into the leaking cell and fill to
the 1/3 level with JP-4 fuel.
One third level is determined from the known capacity of the cell; for example, 100 gads
added to a 300 gallon cell.
Allow the dye solution to set in the cell for approximately 6 hours or until the dye solution comes through the drain.
Should the dye appear, there is a leak within this level.
(2) Repeat the procedure at the 2/3 level and full level, as necessary. A full cell should be allowed to set for
approximately 12 hours.
(3) When a leak is detected, connections should be checked, the cell defueled, and residual fuel removed with
cloths and drained from the sump. Type MA-1 explosion proof blower may be used to remove fumes. Remove all
connections, pull fuel cell down, and check for dye stains on exterior of the cell. These stains are easily detected, thus
pinpointing the leak. Rarely is any maintenance necessary other than replacing seals and retorquing connections.
(4) Check for defective cells (blisters, layer separations, etc.) in accordance with the applicable fuel cell and/or
aircraft maintenance manual.
(5) After closing the fuel cell, the dye solution may be transferred into the fuel cell once more to the three
levels: 1/3, 2/3, and full, thereby ascertaining whether or not the cell still leaks.
(6) After completion of fuel cell leak detection operation, the aircraft may be flown with yellow dyed fuel. Red
dyed fuel can be used provided it is diluted 10 parts to 1 part with undyed


The recent 2021 Brit Awards ceremony, held as part of the government’s Events Research Programme, has registered zero Covid cases.
This year’s edition of the ceremony had a live audience of 4000 fans which was largely comprised of NHS and key workers. The audience was not required to wear masks of social distance, as they had provided a negative coronavirus test beforehand.
As reported by the Evening Standard, no cases of the virus have been linked to the BRITs. Additionally, only 15 positive results came from the 58,000 people who took part in the government’s research events.
Two cases were linked to this month’s Blossoms gig at Liverpool’s Sefton Park, which 5000 people attended. Nine other cases came from The First Dance, the city’s two-day clubbing pilot.
The Culture Secretary Oliver Dowden hailed the results as “a real success” and said he was “very hopeful” that venues would be able to reopen without restrictions on June 21st, vis-a-vis the government’s “roadmap out of lockdown”.
However, the government are still collecting data from other events before Prime Minister Boris Johnson presents a report to the public.
The government has recently commissioned a second set of trial events, and this time they will host larger audiences. This comes shortly after Festival Republic boss, Melvin Benn, revealed plans for a 10,000-capacity festival event in the “middle of June”.
Benn explained: “While the club shows and the Sefton Park pilot (in Liverpool) were effectively events that were designed to ensure the enablement of reopening on June 21st, the camping event, because it’s three or four days, will actually be about testing the protocol of how to deal with anyone that might have Covid at the event”.
Benn, who runs Reading and Leeds Festivals, carried on: “It’s about testing the protocols around using Covid certification on the NHS app, and it’s also around testing the protocols of what the SAGE (Scientific Advisory Group for Emergencies) scientists here in the UK want, which is at-home testing for all attendees that don’t have the vaccination and that are not immune.”
The festival organiser also revealed that he believes that “festival season really can happen” this summer. Reading, Leeds, Latitude and Wireless are just some of the UK festivals scheduled to return this summer.
Watch footage from Blossoms Sefton Park gig, below.


text:
Court finds ex-rector Melnyk not guilty of seizing property
Borodiansky District Court in Kyiv region has found former Rector of the National University of the State Fiscal Service of Ukraine Petro Melnyk not guilty of seizing property through abuse of office.
The respective court ruling, dated December 5, 2017, has been included in the single register of judicial decisions.
The ruling recognizes Melnyk "as innocent in the charges brought for committing a crime under Part 5, Article 191 [misappropriation, embezzlement or acquisition of property by abuse of office in a particularly large amount] of the Criminal Code of Ukraine" and acquits him "under Part 5, Article 191 of the Criminal Code of Ukraine due to the failure of evidence of a crime in his actions."
In addition, the court refused to consider a civil claim lodged by the National University of the State Fiscal Service of Ukraine against Melnyk to compensate UAH 33.444 million for property damage.
The court also lifted the arrest, which was imposed in 2015 by the Shevchenkivsky District Court of Kyiv, from Melnyk's stake in the statutory fund of a scientific and educational center.
"The verdict comes into legal force after the deadline for filing an appeal if such an appeal is not filed. If the appeal is filed, the verdict, if not cancelled, comes into legal force after a decision is made by the court of appeal," reads the ruling.
Melnyk was found innocent in the illegal transfer in favor of his relatives of four real estate objects of the educational institution with a total area of 4,000 square meters, causing over UAH 33 million worth of damage to the state.

domain: news


Modernization and optimization of a positioning system used in a vehicle body warehouse;
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Mercedes Benz Factory in Düsseldorf, Germany
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ARATEC® TPCC® - Registered in U.S. Patent and Trademark Office
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PSI Technics' ARATEC Positioning Solution System is an innovative solution for industrial positioning applications.Show movie
We invite you to experience a completely new type of control technology – in an entertaining short story. A clear and straightforward presentation will show you why the ARATEC is the best positioning solution on the market: For STACKER CRANE applicationsFor BRIDGE CRANE applications
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The ARATEC's FLP6000AOC software reduces mast oscillations – even of highly dynamic stacker cranes – to a minimum. The test setup shows that the ARATEC Positioning Solution System with enabled FLP6000AOC compensates for mast oscillations in near-real time, even when the oscillations are caused by external disturbances.
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56220 Urmitz | Germany
PHONE +49 (0) 2630 91590-0
FAX +49 (0) 2630 91590-99


text:
One of the Melbourne's more enduring family-owned development companies has lodged plans for a soaring 80-level city skyscraper, adding to the long list of 43 proposals to be considered by whatever party forms government after this month's election.
Local developer Brady Group, which has been building units in the city for more than 25 years, is banking on continued heat in the apartment market, submitting a proposal for a thin 220-metre tower on a relatively small 1290-square-metre site at 280 Queen Street.
The three-storey rendered brick office building on the site partially leased to Kliger Partners Lawyers will be demolished to make way for a $150 million tower with a blue curtain wall finish and 589 apartments.
The majority of dwellings - 287 - will have two bedrooms, with 242 one bedders and 36 three bedroom apartments. The tower will also have 14 penthouses on its top levels.
The property was purchased by Chinese national Xuebin Wu for $23.9 million last year.
Mr Wu holds a third portion of the holding company which lodged the plans for the site, suggesting an initial joint capital venture with, or buyout, by Brady.
A Brady Group spokesman said Mr Wu was no longer involved in the project. "It will be a Brady Group development," he said. "Work will start in about 12 months."
The site formerly had a permit for a 57-level commercial building with ground floor retail that was issued in 2013.

domain: economics


BIODEGRADABLE PLANT-BASED RUBBER
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Use 100% biodegradable FSC rubber Yulex Pure on its own or adding a rPET printed layer adhesive to the rubber.
This fabric is Yulex Pure™ which is a natural plant-based foam rubber harvested from rubber trees that are FSC certified. Yulex Pure™ is the world’s first high performing, non-sensitizing, 100% plant-based, ultra-pure natural rubber, sustainably sourced.
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Fabric Sample is Black 2-way stretch or 4-way stretch 100% biodegradable rubber plus with add an optional extra layer that is a laminated recycled polyester rPET with colours or it can be printed to your own pattern. Lamination glue is AquaAlfa water-based glue so there are no more harmful solvents and odours. See further details below.
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Yulex biodegradable plant rubber is made from Guayule (Parthenium argentatum). This material is designed to replace traditional tropical- or petroleum-based rubber in consumer, industrial, and medical products, with the residual agricultural materials utilized as a feedstock for bioenergy.


Typically sold for around $600, the DeWalt isn’t exactly cheap, and you can find similar portable table saws for less. DeWalt itself has several other jobsite table saws for lower prices, though they either lack a stand or feature a flimsier one. However, if you value a sturdy stand and the ability to wheel the collapsed unit around, it’s easy to justify the modest extra expense for this saw.
The warranty is for a period of 3 years which Dewalt provides to all their models irrespective of how good the product functions. The durability is good and also provides a powerful performance with almost 20amps of power generated from the device. The Better the power the better is the outcome of the product. Overall a great product provided by Dewalt.
What We Liked: This table saw kit includes everything you need to get started with a 20-Volt MAX compact half-inch drill driver, two 20-Volt MAX lithium-ion 1.3 Ah battery packs, 20-Volt MAX charger and a carrying bag for the drill. You’ll get a 15-Amp, 4800 RPM motor that has a 32.5-inch rip capacity to handle 4-by-8 plywood or OSB sheets. The table has on-board storage to give you a place to keep your guard, fence, wrenches and miter gauge when you aren’t using them.
Our review of DeWalt table saws focused on two models that are very, very similar and one that harkens great advancements in the tool line that sadly has yet to fully come to fruition. The DWE7491RS and DW745 are very similar. The 7491 is slightly more powerful but also slightly heavier and both have miter gauges that should be replaced when purchasing the saws themselves. But the differences are slight enough that our choice of top pick comes down to the 7491’s larger rip capacity. That’s something that won’t affect a lot of people very often, so if your dollars are tight, you can go with a better for-dollar value with the DW745.
The first step always has to be to make sure that you match a saw with your actual needs. It’s a pretty simple thing to go out and buy the biggest, angriest saw available and call it good. But your genuine needs might be modest enough that the biggest, angriest saw is also too much saw, which means that you’re just throwing away a bunch of money. The same goes for weight. If you’re a small-framed person who has difficulty lugging around heavy, bulky objects, you’ll want to tailor your saw to your frame. If you can’t use it, it’s the same thing as not owning it.
The built-in stand sets this saw apart from competitors since it is actually quite stable out of the box and doesn’t require a custom stand or supports to combat vibration, which are often necessary with cheaper and lighter units. DeWalt sells a nearly identical saw with a less robust stand, and after viewing it in a big box store, I was glad to have this one.
DEWALT table saw holder, mobile / rolling (DW7440RS)


text:
- CREAMY PEANUT BUTTER || 9 lbs deliciously creamy, natural peanut butter. Our peanut butter is made by roasting and grinding blanched, dry roasted peanuts until they are wonderfully creamy
- SALT FREE, UNSWEETENED || This product has just one ingredient - peanuts!
- ETHICALLY SOURCED || Our peanuts are sourced from Nicaragua, Argentina and the USA
- CERTIFIED || Gluten Free Certified, Vegan, Kosher, Non-GMO Verified. No added preservatives
Our natural peanut butter is made by roasting and grinding blanched, dry roasted peanuts until they are wonderfully creamy. This product has just one ingredient - peanuts! Salt free and unsweetened. Peanuts are ethically sourced from Argentina, Nicaragua and the USA. Honest in Trade, Gluten-Free Certified, Vegan, Kosher Certified, and Non-GMO Verified. No preservatives added.
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While refrigeration of this product isn't necessary, if stirring is something you wish to minimize, stir and then refrigerate. Please be aware that if left out at room temperature, natural oil separation will occur.
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domain: food


text:
A Structural Model for Apolipoprotein C-II Amyloid Fibrils: Experimental Characterization and Molecular Dynamics Simulations
Chai Lean Teoh, Chi LL Pham, Nevena Todorova, Andrew Hung, Craig N Lincoln, Emma Lees, Yuen Han Lam, Katrina J Binger, Neil H Thomson, Sheena E Radford, Trevor A Smith, Shirley A Mueller, Andreas Engel, Michael DW Griffin, Irene Yarovsky, Paul R Gooley, Geoffrey J Howlett
Journal of Molecular Biology | ACADEMIC PRESS LTD- ELSEVIER SCIENCE LTD | Published : 2011
Awarded by Australian Research Council
Awarded by ARC Center of Excellence in Coherent X-ray Science
Awarded by Swiss National Foundation
Awarded by Biotechnology and Biological Sciences Research Council
We thank Drs. Terry Mulhern, Danny Hatters, and Michael Bailey for discussions and advice throughout the preparation of this work. This work was funded by grants from the Australian Research Council (DP0877800 and DP0984565) and the ARC Center of Excellence in Coherent X-ray Science (CE0561787). We thank Philippe Ringler for STEM. The STEM experiments were supported by the Swiss National Foundation (grant 3100A0-108299 to A.E.) and by the Maurice E. Muller Foundation of Switzerland. Part of this research was undertaken on beamline MX-2 of the Australian Synchrotron.

domain: biology


WATCH: Cork’s Biggest Liverpool Fan Has Written Some Hilarious Chants For Munster
Latest posts by Will Matthews (see all)
- The Jordie Barrett deal to Leinster opens a massive loophole in the Irish system - April 17, 2024
- More big Irish central contract news that will infuriate some fans - April 17, 2024
- Former Munster star joins Leinster’s coaching ticket - April 16, 2024
This is brilliant.
Kevin Murphy a.k.a “Cork’s biggest Liverpool fan” has swapped the round ball for the oval ball in this brilliant new video from the lads at Keary’s Renault.
Irish comedian Richie Sheehy became an internet sensation this year with his brilliant song about Liverpool’s deadly trio of Sadio Mane, Roberto Firmino and Mohamed Salah.
Now he’s decided to have a crack at creating some timeless classics for Munster, which he has sent to the legendary Doug Howlett for his “approval.”
Aided by the Munster Rugby Supporter’s Club Choir, Murphy has come up with such timeless classics as “Oh Mahony”, “When you play Tyler Bleyendaal” and “I need a Zebo.”
Check out the video below.


The Government of GOA, National Health Mission has issued a notification for the recruitment of 49 Ayush Doctor, General Physician and various posts vacancies.
Educational qualification for National Health Mission recruitment 2017 must be a qualifications and other requirements for the different categories of posts. National Health Mission General Physician Advertisement 2017 candidates age limit must have minimum 22 years and maximum 42 years as on 1st December, 2016 and age relaxation information for OBC, SC/ST category candidates as per govt rules. Shortlist job applicants’ selection will be based on interview NRHM Goa Ayush Doctor Recruitment 2017.
Name of the Post (Designation): Ayush Doctor, General Physician and various post
Educational Qualification: The educational qualifications and other requirements for the different categories of posts
Age Limit: 22-42yrs
Selection Procedure: Interview
Walk in Interview with Dates: 20th-30th available
The Medical Officer of Primary Health Centre (PHC) is responsible for implementing all activities grouped under Health and Family Welfare delivery system in PHC area. He/she is responsible in his individual capacity, as well as over all in charge. It is not possible to enumerate all his tasks. However, by virtue of his designation, it is implied that he will be solely responsible for the proper functioning of the PHC, and activities in relation to RCH, NRHM and other national programs.
The Union Cabinet vide its decision dated 1st May 2013 has approved the launch of National Urban Health Mission (NUHM) as a Sub-mission of an over-arching National Health Mission (NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of National Health Mission. NHM has six financing components: (i) NRHM-RCH Flexipool, (ii) NUHM Flexipool, (iii) Flexible pool for Communicable disease, (iv) Flexible pool for Non communicable disease including Injury and Trauma, (v) Infrastructure Maintenance and (vi) Family Welfare Central Sector component. Within the broad national parameters and priorities, states would have the flexibility to plan and implement state specific action plans. The state PIP would spell out the key strategies, activities undertaken, budgetary requirements and key health outputs and outcomes. The State PIPs would be an aggregate of the district/city health action plans, and include activities to be carried out at the state level. The state PIP will also include all the individual district/city plans. This has several advantages: one, it will strengthen local planning at the district/city level, two, it would ensure approval of adequate resources for high priority district action plans, and three, enable communication of approvals to the districts at the same time as to the state.


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domain: medical


text:
|Year : 2017 | Volume
| Issue : 1 | Page : 29-37
Infected nonunion with implant in situ in long bone fractures, managed by retention of implant-our experience
S. P. S. Gill, Manish Raj, Pulkesh Singh, Dinesh Kumar, Jasveer Singh, Prateek Rastogi
Department of Orthopaedics, UP University of Medical Science, Saifai, Etawah, Uttar Pradesh, India
|Date of Web Publication||29-May-2017|
S. P. S. Gill
Department of Orthopaedics, UP University of Medical Science, Saifai, Etawah, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Early Internal fixation of any fracture now days given us great advantage with relation to early mobilization and early returns to daily activity. Rate of infection related to implant surgery reported by numerous study ranges from 0.5% to 4-5% in closed fractures and up to 10% in cases of compound fractures. Post operative infection with implant in place is one of the most difficult conditions to manage. In our study we tried to retain the implants in these cases and evaluated long term result in these cases. Material and Method: We selected total 108 cases of infected implant without union from regular follow cases of operated post operative cases of upper and lower limb long bones managed by nailing and plating 2006 to 2014. Out of 108 cases 94 cases completed their follow up duration. We managed these cases with retention of implant for as long as possible with regular debridement, incision and drainage, pus culture and sensitivity and antibiotics accordingly off and on till attainment of bony union. Final results were evaluated and any implant failure and other revision surgery rates recorded. Results: Out of 94 cases bony union were achieved in 76 cases (81%) with retention of same implant with proper antibiotic coverage, regular follow up and guarded weight bearing. 8 of our cases shows implant failure due to delayed and non union. In 10 cases, removal of implant was required before bony union. Infection related to implant was also cured once implant were removed after attaining bony union without any long term complications. Conclusion: This increase incidence of infection related to implant also aggravated by various drug resistant microorganism. In most of these cases of infected implant, implants can be retained in situ till bony union achieved. Low grade infection with implant didn't have any severe negative consequence on bony union. This infection can be cured with removal of implant once bony union achieved.
Keywords: Infected implant, long bone infected implants, postoperative infection, retention of infected implant
|How to cite this article:|
Gill S, Raj M, Singh P, Kumar D, Singh J, Rastogi P. Infected nonunion with implant in situ in long bone fractures, managed by retention of implant-our experience. J Orthop Traumatol Rehabil 2017;9:29-37
|How to cite this URL:|
Gill S, Raj M, Singh P, Kumar D, Singh J, Rastogi P. Infected nonunion with implant in situ in long bone fractures, managed by retention of implant-our experience. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2023 Mar 27];9:29-37. Available from: https://www.jotr.in/text.asp?2017/9/1/29/207164
| Introduction|| |
Infection after any orthopedic surgery is one of the most serious complications. In recent past years with a better understanding of asepsis and operative conditions, the incidence of infection declines rapidly after any orthopedic surgery. With the increase in the frequency of high-energy trauma globally and going trend toward the early internal fixation of compound fractures of all bone, the incidence of infection related to orthopedic implant is again showing increasing incidence. This increasing incidence also associated with the emergence of multi-drug resistant microorganism prevalent in hospitals. Infection after any orthopedic surgery is associated with a high morbidity and increase the cost of treatment due to revision surgeries. Till now most of these cases of the infected implant with nonunion managed by removal of that implant with any cement and other foreign material from infected site followed by regular debridement and long-term antibiotics. This leads to unstable fracture site with infection. These cases further required secondary procedures such as ring fixation. These lead to very long morbidity and the high cost of treatment.
Numerous study of retention of the implant with antimicrobial drugs has reported recurrence rate of 69–97% after a variable period of follow-up. In recent past, several studies reporting a high rate of success rate with regular debridement and retention of the implant with controlled infection and shows success rate up to 80% of cases. Main concern with implant-related infection is of biofilm., With a better understanding of biofilm and antimicrobial agents that can penetrate this biofilm prolonged retention of this implant could be possible till union can be achieved. In this study, postoperative cases of fracture with the infected implant in situ selected and prospectively followed-up at regular interval and intervened accordingly. The outcome is recorded and analyzed.
The purpose of the current study was to see that whether infected implant can be retained for the enough duration in situ till the bony union can be achieved without any serious limb- and life-threatening complications. We also aimed to identify other variable related to the success of retention of infected implants such age of the patient, grade of initial soft tissue injury, relation with smoking and tobacco chewing of, the time delay between injury and surgery, fracture communition.
| Materials and Methods|| |
This study was performed in 1000 bedded multispecialty tertiary case specialized Medical Collage UPRIMS and R, Saifai, Etawah, located in North Central India in a rural setup. The patients were selected from the regular follow-up cases of internal fixation done in Department of Orthopedics, which shows sign of infection from internal fixation site from August 2008 to August 2013. Early postoperative follow-up cases with the implant in situ with the sign of infection within 6 weeks of surgery during regular early postoperative follow-up were selected and further evaluated for inclusion in the current study. During this period, totally 118 cases of the infected implant were selected. These cases were investigated and intervention such as local wound debridement, incision, and drainage done and we tried to retain the implant till bony union achieved. Of these 118 cases, 108 cases came under our study inclusion criteria for retention of the implant. Totally 108 cases were included in the study, of these 94 cases completed this regular follow-up with our department. 14 cases did not turned-up during regular follow-up and their final results were not known; hence, they were also excluded from the study. Of 118 cases, only 94 cases were followed-up till the end of follow-up from our side.
- Postoperated case of fracture of long bones managed by internal fixation either nailing or plating showing sign of infection during early follow-up without any bone union
- Cases with radiological and clinical stable internal fixation of fracture site
- Clinical evidence of infection from operated limb before attainment of bony union
- Healthy fracture ends without any bone lyses due to infection.
- Patients with Other systemic disease leading to increase susceptibility to infection like uncontrolled diabetes, HIV and other immunocompromised conditions excluded
- Known cases of multidrug-resistant cases with high-grade infection also excluded
- Unstable fixation or loose fixations cases to start with also not included in this case series
- Radiologically seen bone lysis around fracture and implant also excluded indicating severe infection
- Other systemic conditions with contraindication to the use of long-term antibiotics also excluded.
Postoperative infection defined as redness, swelling, erythema around fracture site and implant insertion site with the collection of pus in tissue, sinus pus discharge, local tenderness and other systemic symptoms of infection like fever. This is further confirmed by pus culture and sensitivity. Cases with negative or sterile pus and culture sensitivity report but giving clinical signs of infection also included in this study.
108 cases were selected from a routine follow-up from 2008 August to 2014 August from orthopedics Out Patient Department of our institution UPRIMS and R, Saifai, Etawah. The cases were followed-up till bony union was achieved and cases were taken for removal of the implant after bony union. 94 cases completed their follow-up. End of follow-up decided by either attainment of bony union followed by implant removal and early removal of the implant before the union. Any removal of the implant before bony union counted as failure case. The cases were selected and further evaluated radiologically, and routine investigations carried out such as complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serum protein with albumin to globulin ratio, local pus microscopy, culture, and sensitivity.,,, Baseline parameters recorded and antibiotics started according to culture and sensitivity. Every case of early postoperative implant-related infection was taken to operation theater for local wound irrigation and debridement. Local aspiration and tissue sampling was done for histopathological investigation. Local aspiration was sent for culture and sensitivity investigation. Every measure was taken to prevent any cross or local contamination during aspiration and tissue sampling. During this early irrigation and debridement, the stability of fixation also assessed and cases with good stable internal fixation only selected for further continuation of retention of the implant. All these cases were kept on intravenous antibiotics for 15 days according to culture and sensitivity report followed by oral antibiotics. Regular follow-up of cases done weekly to assess the effectiveness of given antibiotics. The weekly amount of pus discharge assessed and compared to an earlier visit. Biweekly ESR and CRP of cases also done to see any change of to see the effectiveness of given antimicrobials. Cases responding to drugs further managed on the same line. Those not responding to antimicrobials, reassessment of pus culture done and change in antibiotics carried out. Any collection of superficial of deep pus was watched carefully, and immediate incision and drainage carried out. Radiograph of limb obtained every 4 weeks. During each follow-up, not weight bearing exercise was advised, and joints were mobilized. Partial weight bearing was allowed once there was radiological sign of union seen on follow-up radiograph. Full weight bearing allowed once complete bony union seen on radiograph. The need of dynamization also assessed during follow-up and in some cases dynamization also carried out from the far end of the fracture site. Some of the tibial cases also required fibulectomy as fibula shows early union and now allowing the compression at the fracture site. Cases during follow-up also carefully assessed and evaluated for any sign of implant loosing, failure of fixation, osteolysis at the fracture site and screw site. Any loose fixation and lost reduction seen during follow-up were further managed by other methods such as implant removal, debridement, and external fixation and in some cases delayed revision internal fixation and counted in failure group.
The antimicrobial protocol used was depending on culture and sensitivity of pus collected from the infected site. These antimicrobial were also according to our institutional antimicrobial policy. Response to these antimicrobial also assessed by reduction in swelling and reduction of pus coming out of sinus and also by laboratory investigations such as ESR and CRP. Cases not responding to systemic antimicrobials were further managed by local wound irrigation and local antibiotics beads and repeat culture and sensitivity. These cases were closely monitored and the need for implant removal assessed accordingly. In all of our case, we given oral tab rifampicin 600 one a day for at maximum 3 months or till bony union whichever is earlier. Rifampicin was added for better penetration of antibiotics in biofilms around the implant and its action against Stapylococcus aureus (methicillin resistant)., All cases were evaluated radiologically every 4 weeks and progression of callus formation noted carefully. Furthermore, a sign of bone destruction, bone resorption, and fracture end lysis also noticed. Cases were followed-up to the achievement of the bony union. Bony union determined by radiological bridging callus and no pain over fracture site on weight bearing in lower limb cases.
Of 118 cases, 108 cases fulfilled the inclusion criteria were continued with the same implant and followed-up and intervened in our study as mentioned earlier. Of these 108 cases, 94 cases completed their follow-up with our department. Of 94 cases, 64 were males and 30 were females with an age range from 18 years to 68 years and average age of 36.8 years. Follow-up duration of these cases were range from 15 months to 36 months with an average follow-up duration of 30 months. Of 94 cases, 76 cases were of the lower limb, 46 tibial and 30 femoral implants with the sign of early infection. 18 cases were of upper limb internal fixation and out of these 18 cases 12 were of humerus internal fixation and 6 were of forearm internal fixation. 16 cases of upper limb internal fixation 16 cases were of plating and two cases were of humerus interlocking with infected implant. Of 76 lower limb cases, 55 cases were of locked intramedullary nailing and 21 cases were of plating.
According to Gustilo and Anderson classification,, out of 94 cases 34 were of compound Grade I, 24 cases were of compound Grade II and 20 cases were of compound Grade III group. Rest 16 cases were a closed fracture to start with and acquired infection either per operatively or early postoperatively. All cases of the upper limb infected implant were a closed fracture to start with.
We also recorded the history of smoking and tobacco chewing  from our study group. Out of 94 cases, 40 cases were having history of smoking and tobacco chewing.
Ethical clearance was taken from institutional ethical committee and written informed consent was obtained from each patient. Statistical analysis was performed by our Institutional Statistician from Department of SPM. Chi-square and Fisher's exact tests were performed to identify variable association with the outcome of implant retention. The level of significance was set at P < 0.05.
| Results|| |
Most of earlier studies with postoperative infection with the implant in situ advocated the removal of implants. In our study, we try to retain the implant with controlled infection for as long as possible. We carefully selected 94 cases for this study for retaining the infected implant which full fills our inclusion criteria. Of 94 selected, 46 cases were of tibia fracture with the infected implant and 30 cases were of femur fracture with the infected implant. 18 cases of the infected implant were of upper limb, 12 humerus and 6 forearm cases.
Out of 94 cases, we were able to achieve good to excellent outcome in 76 (81%) cases. During follow-up, of these 94 cases 18 (19%) cases show failure and continuation of the infected implant could not be possible of these cases were immediately discontinued, and other measures were taken to treat these cases such as removal of internal fixation and debridement and external stabilization. Of these 18 failure cases in 10 cases, there was a loss of fixation and loosening of the implant were seen with due course of time due to uncontrolled infection. These cases were come as multidrug resistant cases. In eight cases, implant failure was noted before the union. There was strong association between failure of infected implant retention and grading of soft tissue injury during initial injury. Of 18 failure of implant retention, 15 cases were of Compound Grade III and compound Grade II to starts with which were treated by primary internal fixation.
Out of 46 tibial cases of infected implant 37 cases achieved complete bony union without any serious consequences [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]. 9 cases gone into failure out of 46 tibia fixation with the infected implant. Of these nine cases, five cases were of loosing of the nail with unstable fracture site noticed during follow-up. These cases were further managed by removal of the implant and other methods of fixation like external fixation. In rest four cases implant failure seen due to the delayed union. These cases were also managed by removal of the implant, local debridement, and external fixation. Implant removal were done in 30 of these successful tibial 37 cases after attaining bony union and canal washed thereafter and infection also cured. Other seven cases did not turn up and not given consent for implant removal as they have a little or negligible problem with still implant in situ and in these cases infection also cured after attainment of union. The average duration of implant retention in tibia with bony union cases was 18 weeks with a range from 15 weeks to 27 weeks. All of these cases were advised as soon as there was bony union. These cases were further protected by below knee walking Plaster of Paris (POP) cast for 6 weeks after removal of the implant. Seven cases of failure were further managed by removal of the implant before the bony union, and two of these cases were managed by POP cast with window and other five by external stabilization. All these cases also attained union by other methods without any serious consequences.
|Figure 1: (a) Communited fracture upper end of tibia. (b) Fracture managed by lateral tibia plating by minimally invasive percutaneous plate osteosynthesis method. (c) Infection noticed during regular follow-up in case of tibia plating, managed by local cleaning and proper antibiotics and retention of plate. (d) Infected implant managed by retention of implant and in follow-up radiograph callus formation seen. (e) Final outcome with retention of infected plate|
Click here to view
|Figure 2: (a) Fracture both bone leg distal end. (b) Fracture both bone leg managed by plating. (c) Plate insertion site of both bone fracture got infected with skin slough and pus discharge. (d) Follow.up radiograph at 10. weeks with union in progress with retention of same infected implant|
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|Figure 3: (a) Case of tibia interlocking. (b) Tibia nail got infected with sinus discharge, managed by retention of implant. (c) Union seen after 14 weeks with retention of infected tibia nail implant|
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|Figure 4: (a) Compound Fracture bone bone leg. (b) Fracture both bone leg managed by interlocking nail. (c) During follow.up, pus discharging sinus noticed, nail got infected. (d) Follow.up radiograph at 12. weeks, union achieved with retention of infected tibia nail|
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|Figure 5: (a) Fracture both bone leg. (b) Case of fracture both bone leg managed by interlocking nail. (c) Interlocking nail got infected with swelling and subcutaneous pus collection. (d) Union achieved with retention of same infected implant|
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Out of 30 femur cases of the infected implant, 26 cases shows complete bony union during follow-up with retained implant without any further complications [Figure 6],[Figure 7],[Figure 8]. In two cases implant loosing seen and two cases of implant failure seen in femur nailing cases. These four cases were further managed by implant removal and delayed secondary nailing. Out of 26 of these cases, 20 cases agreed for removal of the implant after bony union. Rest cases not given the consent for the removal of the implant as again they have a little or negligible problem with still implant in situ and in these cases infection also cured after attainment of union The average follow-up duration of femur cases were 32 weeks. The average union time in femur cases with the infected implant in situ were 18 weeks and ranged from 14 weeks to 22 weeks. Four failure cases were of compound Grade III supracondylar fracture of the femur to start with, two treated by retrograde nailing and two by distal femur LCP. These four cases were managed by removal of implant, debridement, high tibial skeletal traction, and delayed internal fixation once the infection was controlled.
|Figure 6: (a) Supracondylar fracture of femur. (b) Supracondylar fracture of femur managed by retrograde femoral nailing. (c) Supracondylar nail of femur got infected with pus discharging sinus. (d) Follow-up radiograph of retrograde femoral nail 12 weeks with retention of infected implant.|
(e) Follow-up radiograph at 16 weeks with retention of infected implant, complete union achieved
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|Figure 7: (a) Femur fracture managed by open K nail. (b) Infection noticed with nail of femur. (c) Callus seen during follow.up at 8. weeks with infected implant in. situ. (d) Final outcome at 12. weeks, bony union seen, with infected implant in situ|
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|Figure 8: (a) Supracondylar fracture of Femur with bone loss. (b) Supracondylar fracture managed by primary plating. (c) During follow.up of plating case, sinus discharge noticed. (d) Case of infected plating managed by retention of same implant. (e) Continuation with infected implant retention, bony union achieved|
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Out of 18 cases of the upper limb with retained infected implant, 13 cases show bony union without any other serious complications [Figure 9] and [Figure 10] and in all of these cases infection was cured after removal of the implant once the union was achieved. Rest five cases of upper limb show failure in retention of the infected implant. Out of 5 failures, 3 were of both bone forearm plating with retained infected implant and two cases were of the humerus with retained infected impact. Out of two humerus failure cases, one was of plating and one was of nailing. These five failure cases of upper limb were further managed by removal of the implant and local control of infection and external fixation. None of these cases gone to any serious complications such as neurovascular damage or amputation. Average union time of 12 successful cases was 15 weeks with a range from 13 weeks to 24 weeks.
|Figure 9: (a) Case of humerus fracture managed by plating. (b) During follow.up implant got infected, managed by retention of implant. (c) Union achieved with retention of infected implant|
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|Figure 10: (a) Supracondylar fracture of humerus. (b) Supracondylar fracture of humerus managed by elbow reconstruction plating. (c) Postoperative sinus discharge with implant in place (d) Infected implant managed by retention of implant and in follow-up radiograph callus formation seen. (e) Final outcome with retention of infected plate|
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Other factors associated with failure of the infected implant were also analyzed. These are an association with tobacco chewer and smoking, socioeconomical status, and nutritional status of patients, patient's compliance with the treatment protocol, patient's apprehension with retention of the infected implant.
About 40% of cases of successful implant retention were smokers to start with and were advised to stop smoking and there compliance of stopped smoking cannot be assessed. About 60% of cases of failure group were smokers to start with. There were an overall relation of smoking and tobacco chewing wit delayed union and nonunion, but in our follow-up, a strong relation between failure of implant retention and smoking and tobacco chewing cannot be stabilised. There was a strong association between severity of compounding to the failure of retention of implant group. 85% (15 cases) of cases of implant retention failure were of compound Grade III or compound Grade II group to start with.
There was also a strong association between levels of antimicrobial resistance to the success of retention of the implant. 90% cases of multidrug-resistant microorganism case gone into failure group. Methicillin resistant S. aureus (MRSA) was one of the constant microorganisms seen in long-term failure cases.
| Discussion|| |
Traditionally, management of postoperative infection includes a prolonged course of an antimicrobial agent, aggressive debridement, and most importantly, removal of the infected implant. Steckelberg and Osmon. in his study found the success rate of more than 80% in cases of prosthetic infections but had its own complication including prolonged immobilization, unstable fracture site, and poor patient compliance. Recently, several investigators suggest that the fracture will heal in the presence of infections as long as the fixation material remains stable.
Rightmire et al. in their study on acute infections after fracture repair: Management with hardware in place showed 47 (68%) were successful and 22 (32%) were unsuccessful. They also said that smoking was a major risk factor with a 3.7 times greater likelihood of procedures being unsuccessful, thus treating infected fractures with hardware in place is less successful than widely believed.
In 1996, Tsukayama, Estrada and Gustilo  reported a success rate of 68%, but debridement with retention of the implant was limited only to infections of short duration <1 month after surgery. In 2003, Meehan et al. reported 1 year recurrence-free rate of 89%, but only infections with penicillin-susceptible streptococci were included.
The stability provided by the implants has been proved to reduce the incidence of infection after internal fixation, and to aid in the clearance of established infections, thus making the maintenance of fixation a top priority.
Berkes et al. retrospectively analyzed 123 postoperative wound infections that had developed within 6 weeks after internal fixation of a fracture and found that 87 patients (71%) had fracture union with operative debridement, retention of hardware, and culture-specific antibiotic treatment.
In an experimental study, Warlock et al. fixed diaphyseal fractures of the tibia with a stable compression plate or with an unstable endomedular pin, and inoculated S. aureus in the fracture zone. They found out that in the unstable group there were 2 times more infections than in the stable compression plate group (71% vs. 35%).
As literature does not suggest any guidelines to dictate whether implant should be removed or retained in the presence of an acute infection, the management requires flexibility in the treatment plan while trying to avoid a poor outcome such as infected nonunion. According to the available literature, it is recommendable to maintain the hardware in place till osseous union has occurred. This study suggests it is possible to achieve union and resolve infection with the implant in place.
Chen et al. in their work on Infection after intramedullary nailing of the femur postulated that retention of the intramedullary nail can be performed if the fixation is stable and the infection is under control.
Viol et al. worked on soft tissue defects and exposed hardware and identified parameters for the potential salvage of exposed hardware with soft tissue coverage. If stable hardware, time of exposure <2 weeks, control of infection, and location of hardware salvage of the hardware with plastic surgical soft tissue coverage is possible.
Zych and Hutson  in their work on diagnosis and management of infection after tibial intramedullary nailing showed 20 patients with an infection after intramedullary nailing of the tibia, treatment protocols were based on the time of onset of infection (acute, subacute, and chronic) and the status of bone healing. Acute infection group managed successfully with nail retention, debridement, soft tissue coverage, and IV antibiotics.
Gristina, on their work on mechanisms of musculoskeletal sepsis shows clinical infection is multifactorial and may include the formation of a biofilm. Due to the adsorption of proteins, sugars, and other macromolecules onto the implant surface; possible changes in the material itself attributable to the host or the bacteria; the effects of the implant on the local environment; and the systemic effects of the implant in the host.
Merritt and Dowd  worked on the role of internal fixation in infection of open fractures studies with S. aureus and Proteus mirabilis and noticed that Infection rates in fixed and unfixed fractures were compared, the infection rate at 2 weeks was lower in the internally fixed fractures than in the unfixed fractures. However, g negative proteus infections worse in the internally fixed group. Stability lowers incidence of S. aureus infection.
Friedrich and Klaue  worked on Mechanical stability and post-traumatic osteitis: An experimental evaluation of the relation between infection of bone and internal fixation and seen that abscesses, sinuses, and sequestra developed in 45% of the unstable fractures, whereas clinically manifest osteitis did not occur after rigid fixation. With rigid fixation, there was no significant difference in the time to bony union between the infected and uninfected fractures.
In this study, our main aim was to retain the infected implant in situ as long as possible to attain bony union without any serious complications. There is great apprehension among patients and also in treating regarding infection after any orthopedic surgery. Numerous studies have proven that there is no significant difference in the time of bony union between the infected and uninfected fracture, but the mail concern is fracture stability. This infection may convert initial rigid internal fixation into loose internal fixation. This is the main concern with relation to retained infected implant. To prevent this loosing of initial stable internal fixation we take every measure to control the infection with proper debridement, drainage of any collection and proper antimicrobials. This was also seen in previous studies that stable fixation is also associated with low infection rate. Out of 108 cases included in our study, 94 cases completed our full study follow-up duration. We were able to achieve 81% success rate with relation to the bony union. All of these cases we were succeeded to retain implant for enough duration with a regular timely intervention like debridement, incision and drainage and antimicrobial suppression so that these cases can achieve bony union. We added tab rifampicin 600 mg daily in the morning in every cases of the infected implant as a universal positive factor for action against biofilm and MRSA. There were also difficulties in explaining regarding the retention of the implant with infection till bony union. But with proper counseling and explanation we were able to obtain consent from all of these cases. There were great apprehensions in society regarding discharging sinus and infection after orthopedic implant surgery and also for retaining of these implants in situ.
Cases from low socioeconomical status given poor outcomes of retention of infected implant. Causes are multifactorial as they are generally not strict to nonweight bearing protocol so prone to implant loosing, also difficult for them in continuation of long-term antibiotics. Poor nutrition also contributes to failure in these cases. Of 94 cases, 70% cases were from low socioeconomic status as our institute is government hospital located at rural setup. Out of 18 failure cases, 90% (16 cases) were of low socioeconomic status.
Most of our cases after attaining bony union gone for implant removal surgery and in all of these cases infection were cured within few days to weeks of removal of the implant.
In 18 failure cases, the most common cause of failure was loosing of implant and loss in stable fixation. This leads to further increase in grade of infection and infection further loosens the implant. These all cases were further managed by implant removal, thorough debridement, repeat culture, external stabilization, and delayed secondary procedures such as external fixation and delayed internal fixation. In all of these cases, bony union achieved without any limb-threatening of live-threatening complications.
| Conclusion|| |
Postoperative implant-related infection of long bones fracture can be well-managed by retention of same primary internal fixation till the bony union under proper antimicrobial suppression of infection, repeated minor interventions such as debridement, incision, and drainage, and also it should make sure that internal fixation is stable. Any sign of implant loosing and loss of stable fixation should be discontinued from implant retention protocol and should be further managed by removal of implant and other delayed internal or external fixation.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
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By Daniel Wilson.
Since making his Formula One debut in Melbourne last year, Max Verstappen has surprised even himself with just how fast he has risen through the ranks, and the sea of Dutch flags in the packed grandstands at Spa on Sunday is all the proof you need of this.
Still a teenager, he has already been promoted to the senior Red Bull team and broken records since doing so.
But in recent races, his star appeal has attracted some criticism from the media and most notably, his fellow drivers.
Sunday’s Belgian Grand Prix was the latest race where the Dutchman left as the main talking point. After becoming the youngest driver in 50 years to start a race on the front row of the grid, Verstappen attracted anger from the likes of Kimi Raikkonen after an aggressive move into the first corner, which forced the Finn to collide with teammate Sebastian Vettel.
Raikkonen also accused Verstappen of dangerous driving for making a late defensive move up the hill from Eau Rouge, when the Ferrari driver had to brake at 200mph to avoid hitting the Red Bull.
Spa wasn’t the first time the two drivers had got in each other’s way. Raikkonen criticised the Dutchman for a similar move at the Hungarian Grand Prix last month when he made two direction changes in the braking zone of turn two, which resulted in Kimi damaging his front wing while battling for fifth place.
Nico Rosberg has also been vocal against Verstappen, calling him up on a late change of direction in the braking zone of the hairpin at the German Grand Prix. However, Rosberg was penalised for forcing Max off the track as a result.
So, is he dangerous? Well, Kimi thinks so. He said on Sunday that Max ‘will’ cause a serious incident in the future. But is that a bad thing?
I personally think Max is brilliant for the sport, and while his driving style is controversial, it’s largely paying dividends. He’s already become the youngest ever race winner and has a few podiums to add to his growing trophy collection.
We all know that fortune favours the brave, and Max’s seemingly impossible overtakes around the outside of Blonchimont at Spa and Becketts at Silverstone are no doubt stained into the history books.
The stewards seem to have the same view on him. He’s avoided penalties and he’s bringing life back into F1, which is exactly what it needs. He’s divisive, dangerous and dazzling – and that quite literally, is a winning combination.