Rajesh Malhotra

Five-year profile of candidaemia at an Indian trauma centre: High rates of Candida auris blood stream infections

Candidaemia is a potentially fatal infection with varied distribution of Candida species and their antifungal susceptibility profiles. The recent emergence of Candida auris in invasive candidiasis is a cause for concern. This study describes the profile of candidaemia at an Indian tertiary care hospital and reports the emergence of C. auris. All patients diagnosed with candidaemia between 2012 and 2017 were studied. The isolates were identified using conventional methods, VITEK 2 and MALDI‐TOF MS. The isolates not identified by MALDI‐TOF were sequenced. Antifungal susceptibility testing was done by the CLSI broth microdilution method and VITEK 2. A total of 114 isolates of Candida species were analysed. Candida tropicalis (39.4%) was the most common species, followed by C. auris (17.5%), C. albicans (14%) and C. parapsilosis (11.4%). Notably, Diutina mesorugosa isolates (n = 10) were not identified by MALDI‐TOF and were confirmed by sequencing. Furthermore, 45% (n = 9) C. auris strains exhibited low MICs of FLU (0.05‐4 μg/mL) and the remaining 55% (n = 11) isolates had high MICs ≥ 64 μg/mL. Also, D. mesorugosa exhibited high MICs of FLU (32 μg/mL) in 2 isolates. A high rate of errors in antifungal susceptibility was noted with the VITEK 2 as compared to the CLSI method. Candida auris was the second most prevalent species causing candidaemia warranting infection control practices to be strengthened to prevent its spread.

Simultaneous anterior cruciate ligament repair and medial unicompartmental knee replacement

We present the case of a 55-year-old female who sustained avulsion of anterior cruciate ligament (ACL) from its tibial attachment while undergoing unicompartmental knee replacement (UKR). The fibers of ACL were intact. Realizing the paramount importance of ACL in a knee undergoing UKR, we promptly performed a primary repair of the ACL and continued with the surgery in the same sitting. At the latest follow-up, the patient is doing well both clinically and functionally and has no antero-posterior or varus-valgus laxity. We discuss the cause for ACL avulsion during UKR and precautions to avoid it.

Ceramic trapezio-metacarpal arthroplasty: Probably half is better than full

Trapezio-metacarpal arthroplasty is one of the several treatment options available for painful first carpo-metacarpal (CMC) osteoarthritis of hand. In India, we have only Moje ceramic implants available for CMC arthroplasty. Although the literature cites high frequency of loosening and failure with use of Moje ceramic prostheses, all these studies describe results with total carpometacarpal arthroplasty. We expected that hemi-arthroplasty alone, by virtue of trapezium preservation leading to optimal capsular and ligament tensioning will provide good outcome. We wish to present first case of long-term successful outcome of Moje hemi trapezio-metacarpal arthroplasty from India as well as internationally.

Comment on Stern et al.: Prospective randomised study comparing screw versus helical blade in the treatment of low-energy trochanteric fractures

We admire the work of Richard Stern et al. on the cephalic implant to be used in the treatment of low-energy trochanteric fractures [1]. The authors have conducted a randomised controlled trial and concluded that both screw and a blade perform equally well with a SHS or IM nail for the treatment of trochanteric fractures in the elderly age group. The primary idea of treatment of a trochanteric fracture with a DHS or an IM nail is procurement of controlled fracture impaction by the cephalic implant in femoral head with plate or a nail acting as a lateral tension band. This allows unimpeded healing in a cancellous environment of the extracapsular intertrochanteric region. Thus, there is a constant race between the fracture healing by collapse and tendency for implant failure typified by cephalic implant cut-out. Most trochanteric fractures heal uneventfully with good clinical and radiological outcome. However, some of them, especially the unstable ones and those with delayed union, may end up in varus malunion due to the combined effects of fracture collapse, lack of posteromedial buttress and poor anchorage of the cephalic implant resulting in suboptimal clinical and radiological outcome. Rarely, the tendency for implant cut-out may win the race over fracture healing, resulting in implant failure and worse clinical result. Before moving into a discussion of the article by Stern et al., we describe the proposed advantages of a helical blade. The helical blade allows for compaction of the bone during insertion, an advantage in osteoporotic bone. Improved rotational stability along with better anchorage in a cancellous environment is supposed to reduce the risk of screw cut-out, delayed union and varus malunion. The higher resistance of helical blade to heavy loads and reduced chance of screw cut-out has been made evident by various anatomical and biomechanical studies [2–5]. However the proposed benefits of helical blade have not been construed by any clinical studies to demand a change in the conventional practice. There are a few issues which need to be addressed in the article by Stern et al.: The quality of reduction has been shown to affect the outcome in trochanteric fractures [6]. Only the tip apex distance (TAD) and position of the implant in the femoral head in the immediate postoperative radiographs have been compared between the two groups including cases of implant cut-out. Appended information about the quality of reduction in these radiographs in cases that healed uneventfully and ones with screw cut-out would have added more enlightenment into the quandary. As discussed above the helical blade is supposed to reduce the risk of cut-out, varus malunion and delayed union. Thus, clinical validation of helical blade in the management of a trochanteric fracture should be based on implant position in the femoral head, incidence of varus malunion, re-operation rates and implant failure and include time of healing complemented by clinical outcome. The authors have considered only the re-operation rates along with incidence of cephalic implant cut-out and these cases constitute only the tip of the iceberg. Although the limitation of lack of complete evaluation of patients at one-year follow up was addressed, such a prime study with randomisation and good number of subjects should have thrown light on the incidence of varus malunion, time of fracture healing and clinical outcome by appropriate radiological and clinical evaluation. These would have made the article more edifying and denouements of such a unique clinical study would have more impact in clinical decision making.