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rheumatoid arthritis ); medications ( systemic corticosteroids , bDMARDs ); previous arthroplasty and / or surgical site infection ; and postoperative surgical complications ( such as wound dehiscence or haematoma ).
Additionally , intra-articular injection of corticosteroids in the three months before surgery is a significant modifiable risk factor for the development of a PJI . 3 The risk is slightly higher in regard to TKR than THR .
The International Consensus on Periprosthetic Infection brings together surgeons and physicians from around the world to develop best practice for the prevention , diagnosis and treatment of PJI . The strength of the evidence around the risk of PJI following steroid injection led the consensus to publish a statement at its last meeting that : “ There is strong evidence that surgery should be absolutely delayed for
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a minimum of three months following intraarticular steroid injections .” 3
The consensus last met in 2018 and is next due to convene in 2025 .
It is essential that clinicians who care for patients with hip or knee arthritis , who are considering joint replacement surgery , take this risk into account in the lead-up to potential surgery . If a patient has a corticosteroid injection prior to their orthopaedic consultation , this may lead to a delay in their surgery , due to the increased risk of PJI . Patients who are distressed and in pain may ask for an injection to ‘ tide them over ’, and an injection is also frequently suggested by radiologists . It is essential to keep in mind the impact of any modifiable risk factors for PJI when managing these patients with end-stage arthritis .
References on request from kate . kelso @ adg . com . au
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Periprosthetic joint infections account for over 23 % of primary total hip replacement revisions .
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ANSWER The answer is d . Acne keloidalis nuchae , also known as folliculitis keloidalis nuchae , is a common disorder caused by chronic irritation or occlusion of hair follicles at the posterior neck and occipital scalp leading to the formation of keloid-like scars and scarring alopecia . 1 Active lesions may be painful , pruritic , and have contact bleeding . The pruritus associated with this condition contributes to a cycle of itching , scratching , irritation and inflammation . The diagnosis is clinical , without the need for biopsy . On examination , early presentations appear as erythematous papules and pustules . 1 Over time , fibrosis causes variably sized keloidal papules , plaques or nodules . 1
Triggers include hair cutting practices such as close shaving , friction ( eg , helmets , tight shirt collars ), heat and / or humidity . 2 Young males with afro-textured hair are most prone to this condition because when coarse , curly hair is cut short , the hair shafts can re-enter the skin a short distance from the follicle after exiting the skin ( termed extrafollicular penetration ) or through piercing the follicular wall without emerging from the skin surface ( termed transfollicular penetration ), leading to inflammation . 3 Genetic factors may also play a role , the presence of substitution mutation in 1A helical segment of follicle-specific keratin 75 increases the risk of the condition by sixfold . 3
To limit progression , counsel patients to avoid close shaving , frequent haircuts , friction , rubbing , and skin picking . Management of mild disease involves a combination of high potency topical steroids ( eg , clobetasol 0.05 %), antimicrobial wash ( eg , chlorhexidine , povidone iodine ), topical retinoids ( eg , tazarotene 0.05 % or 0.1 %), with the addition of topical antibiotics ( eg , clindamycin phosphate 1 %) if mild pustules are present . 1 Topical steroids should be applied 1-2 times daily and alternating in two-week cycles to minimise the side effects of long-term use . 1 The condition often improves within 6-8 weeks of treatment , but treatment should be continued until clinical signs and symptoms resolve . If infection is suspected , a culture should be performed and a course of appropriate antibiotics completed prior to starting steroid treatment .
If firm papules or keloid-like scars are present , intralesional triamcinolone injections ( 2.5-40mg / mL ) can be administered at four-week intervals to soften and decrease the size of the lesions . 1 , 2 Treatment-resistant or moderate to severe acne keloidalis nuchae requires systemic treatment with oral antibiotics ( doxycycline or minocycline ) for several weeks to months . 1
References on request from kate . kelso @ adg . com . au
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