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Original article
Incidence of hip and knee prosthetic infections in a specialised centre of Mexico City
Incidencia de infecciones protésicas primarias de cadera y rodilla en un centro de la Ciudad de México
Rafael Franco-Cendejasa,
Corresponding author
raffcend@yahoo.com

Corresponding author at: Av. México-Xochimilco No. 289, Col. Arenal de Guadalupe, C.P. 14389, Del. Tlalpan, Mexico City, Mexico. Tel.: +52 55 5999 1000ext.14801; fax: +52 55 5603 9127.
, Erika Lizbeth Contreras-Córdovaa, Jaime Arturo Mondragón-Eguiluza, Edgar Samuel Vanegas-Rodrígueza, Víctor Manuel Ilizaliturri-Sánchezb, Arturo Galindo-Fragac
a Laboratorio de Infectología, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
b Servicio de Reconstrucción Articular de Cadera y Rodilla, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
c Subdirección de Epidemiología Hospitalaria y Control de la Calidad de la Atención Médica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Arthroplasties have been demonstrated to be the most effective treatment for patients with serious joint disease or end-stage joints&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> The indication for the procedure depends on the functional impact and pain caused by joint degeneration and&#44; moreover&#44; on the quality of the reconstruction expected and its maintenance over time&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">2</span></a> The number of primary total knee and hip arthroplasties has increased over the past decade&#44; as shown in a study in the United States&#44; with almost 800&#44;000 procedures in 2006&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">3</span></a> This type of treatment is considered to have a survival rate from 10 to 23 years for 75&#8211;98&#37; of the procedures&#44; and therefore is considered appropriate treatment to reduce pain and promote functionality&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The causes of failure include aseptic weakening&#44; infection&#44; dislocation and fracture of the bone or prosthesis&#46; The frequency of infection has been observed to increased in relation to the number of primary arthroplasties&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">5</span></a> Infection&#44; although rare&#44; is the most serious complication&#58; it occurs in 0&#46;8&#8211;1&#46;9&#37; of knee arthroplasties and in 0&#46;3&#8211;1&#46;7&#37; of hip arthroplasties&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">6</span></a> Mexican data from retrospective studies over a period of 5&#8211;10 years report from 3&#46;7&#37; to 4&#46;3&#37;&#44; respectively&#44; in knee arthroplasties&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Various risk factors have been identified associated with the infectious process&#44; such as&#58; revision arthroscopy&#44; previous infection associated with a prosthesis in the same site&#44; smoking&#44; obesity&#44; rheumatoid arthritis&#44; cancer&#44; immunosuppression and diabetes mellitus&#46; And finally&#44; postoperative factors such as surgical wound complications &#40;for example&#44; superficial infection&#44; haematoma&#44; necrosis and wound dehiscence&#41;&#44; atrial fibrillation&#44; myocardial infarction&#44; urinary tract infection&#44; prolonged hospital stay&#44; and <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteriaemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">9&#8211;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Often skin bacteria are inoculated into the implant&#59; however&#44; in some cases&#44; microorganisms infect the prosthesis by haematogenous spread or through local compromised tissues&#46; Infections associated with joint prostheses can be classified as early &#40;within the first 3 months following surgery&#41; or delayed &#40;from 3 to 24 months postoperatively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">14</span></a> It is vitally important to diagnose a prosthetic infection&#46; However&#44; this is challenging for many reasons&#58; pathogenic bacteria of less virulence&#44; the pathogenesis and response of the patient&#46; Although there is no universally accepted definition for this type of infection&#44; a consensus has been recently formulated to standardise diagnostic behaviours&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">15</span></a> The treatment of prosthetic infections is usually both medical and surgical&#46; The time and type of treatment depends on the cause&#44; time of infection and the condition of the host&#46; Since multiple surgical treatments are required and prolonged medical treatment&#44; the cost of this disease can exceed 50&#44;000 dollars when sensitive microorganisms are involved&#44; and 100&#44;000 dollars with resistant microorganisms&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Since there are no national data on the incidence of infectious complications of these types of joint procedures&#44; by means of strict follow-up of patients and a well-established diagnosis&#44; the objective of this study was to determine the incidence and the risk factors associated with primary hip and knee prosthetic infections&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">All the patients aged over 18 years who underwent placement of a primary hip or knee prosthesis in the hip and knee reconstruction department of the <span class="elsevierStyleItalic">Instituto Nacional de Rehabilitaci&#243;n</span> during the period 1 August 2011&#8211;31 July 2012&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">General information on the patients was taken from their assessment and follow-up period&#46; During their hospitalisation&#44; data were gathered that might have been implicated in the development of infection&#46; The patients were followed up with visits after their discharge from hospital at 15&#44; 30&#44; 90&#44; 180 and 360 days&#46; An intentional search was carried out for erythema&#44; oedema&#44; hyperthermia&#44; pain or secretion from the surgical wound&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the event that the patients had not attended one of their follow-up sessions&#44; they were contacted by telephone to assess their progress&#44; and the cases with the possibility of infection were advised to attend an assessment&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Primary hip or knee prosthetic infection was defined according to the latest international consensus&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">15</span></a> with the following criteria&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Isolation of the same microorganism in 2 periprosthetic cultures&#44; or</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">A tract communicating between the prosthesis and the outside &#40;fistula&#41;&#44; or</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The presence of at least 3 of the following criteria&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">a&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Elevated C reactive protein and erythrocyte sedimentation rate&#44;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">b&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Elevated leucocyte count or positive leucocyte esterase in synovial fluid&#44;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">c&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Elevated polymorphonuclear neutrophil count in synovial fluid&#44;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">d&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Positive biopsy for periprosthetic tissue infection or&#44;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">e&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Positive periprosthetic tissue culture&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">An infectious disease specialist was included at all times in the assessment of the cases&#46; If a prosthetic infection process was identified&#44; treatment was given according to the clinical presentation of each patient and as stipulated in the department&#39;s clinical guidelines&#44; with microbiological isolation of each case&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">Descriptive analysis of the data was performed using measures of central tendency and dispersion &#40;mean&#177;deviation&#59; median and minimum&#8211;maximum values&#41; for the quantitative variables &#40;continual or dimensional&#41;&#44; in which initially the normality of the distribution used was evaluated using bias and kurtosis indicators&#46; Absolute and relative frequencies &#40;percentages&#41; were used for the qualitative variables&#46; The cumulative incidence and density of incidence were calculated&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ethical considerations</span><p id="par0100" class="elsevierStylePara elsevierViewall">The protocol was assessed and approved by the Research Committee of the <span class="elsevierStyleItalic">Instituto Nacional de Rehabilitaci&#243;n</span> with number 22&#47;12&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">From the period between August 2011 and July 2012&#44; 339 patients with primary arthroplasties of the hip and knee were included&#44; who underwent 179 to 160 procedures&#44; respectively&#46; One hundred and fourteen &#40;63&#46;6&#37;&#41; hip prostheses were placed and 115 &#40;71&#46;8&#37;&#41; knee prostheses in females&#46; Hip arthroplasty was performed more often in younger patients than knee arthroplasty&#44; with a median of 60 years&#46; In terms of educational level&#44; those who underwent hip arthroplasty more often were educated to intermediate or higher level and higher level compared to those who underwent arthroplasty of the knee &#40;116 vs 64&#41;&#46; Of the foreign patients included in the cohort&#44; 22&#46;3&#37; underwent arthroplasty of the hip and 21&#46;8&#37; of the knee&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In terms of history&#44; 94 &#40;52&#46;5&#37;&#41; hip and 105 knee &#40;65&#37;&#41; patients presented comorbidities&#59; high blood pressure and diabetes mellitus predominated&#46; Patients with rheumatoid disease underwent knee arthroplasties more frequently&#46; Thirty-five percent of the hip patients were active smokers compared to 18&#46;7&#37; of the knee patients&#46; There were more patients with surgical risk <span class="elsevierStyleSmallCaps">ii</span> or greater according to the American Society of Anaesthesiologists &#40;ASA&#41; among those who underwent knee than those who underwent hip arthroplasty &#40;79&#46;8 vs 69&#46;9&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">There was a mean body mass index of below 30 in both procedures&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The principal cause for prosthesis placement was arthrosis&#46; We observed that there were other causes for the patients with hip arthroplasties&#59; the most frequent was fracture and its sequelae &#40;18&#59; 10&#37;&#41;&#44; as well as congenital hip dysplasia &#40;10&#59; 5&#46;5&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis was given before surgery for 153 &#40;93&#46;8&#37;&#41; hip and for 125 &#40;89&#46;2&#37;&#41; knee patients&#46; The main drug used was a first generation cephalosporin &#40;cephalotin&#41;&#59; the patients who were allergic to penicillin were given levofloxacin for prophylaxis&#46; The median administration time of antibiotic prophylaxis was 93<span class="elsevierStyleHsp" style=""></span>min &#40;9&#8211;300&#41; for the hip and 78<span class="elsevierStyleHsp" style=""></span>min &#40;1&#8211;315&#41; for the knee&#44; before the start of surgery&#46; The median postsurgical duration of said antibiotic was 12 days&#46; The patients who underwent hip arthroplasties received more transfusions than those who underwent knee arthroplasty&#44; who most often suffered hypothermia and more incidents during the surgery&#46; The hospital stay was a median of 6 days &#40;4&#8211;22&#41; for the hip and 4 days &#40;3&#46;12&#41; for the knee&#46; Twenty visits were recorded to the emergency department by the hip patients&#44; of which 10 &#40;5&#46;5&#37;&#41; were associated with the surgery&#44; such as dislocation&#44; trauma&#44; surgical wound condition and others&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Two patients had surgical wound infection after hip arthroplasty and 3 patients after knee arthroplasty&#46; It was possible to record the complete progress of 166 &#40;92&#46;7&#37;&#41; patients who underwent hip arthroplasty and 153 &#40;95&#46;6&#37;&#41; who underwent knee arthroplasties over one year&#39;s follow-up&#59; with a median total follow-up of 402 days &#40;365&#8211;740&#41; and 390 days &#40;365&#8211;728&#41;&#44; respectively&#46; Twenty censorings were obtained&#46; Follow-up after discharge from hospital is described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Infection developed in the prostheses of 6 patients&#44; 4 hip and 2 knee&#44; which are described in detail in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; In the 5 &#40;83&#37;&#41; patients with infection&#44; the infection occurred during the acute period&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the microorganisms involved&#46; The other infections that it was possible to document were 5 surgical wound infections and one urinary tract infection that was complicated with bacteriaemia&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The general cumulative incidence of prosthetic infection was 1&#46;79&#47;339 &#40;CI 0&#46;3&#8211;2&#46;3&#37;&#41;&#59; for hip 2&#46;2&#47;179 &#40;CI 0&#46;5&#8211;2&#46;5&#37;&#41; and for knee arthroplasty 1&#46;25&#47;160 &#40;CI 0&#8211;2&#37;&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The density of incidence was 0&#46;02&#47;year for hip arthroplasties and 0&#46;011&#47;year for knee arthroplasties&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">Joint wear causes pain and dysfunction long term&#44; which affects quality of life&#46; When conservative treatment fails to relieve hip or knee joint pain or dysfunction&#44; total arthroplasty is indicated&#46; This is an elective procedure that can considerably improve pain and function&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">17&#8211;19</span></a> More than 168&#44;000 hip and more than 267&#44;000 knee arthroplasties are performed annually in the United States and it is expected that 571&#44;000 hip arthroplasties will be performed by 2030 according to projections&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a> Improved surgical techniques&#44; reduced operating time and prophylactic antibiotics have reduced the &#40;infection&#41; incidence to 1&#8211;2&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">5</span></a> Using the data from patients hospitalised nationally in the United States&#44; Kurtz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> found an incidence &#40;of infection&#41; ranging between 2&#46;0&#37; and 2&#46;4&#37; of total arthroplasties of the hip and knee respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> Participation by hospitals in the nosocomial infections surveillance system &#40;NNIS&#41; in the United States is voluntary&#44; therefore the data in this system might have selection bias&#58; the NNIS index might not ensure appropriate stratification of this type of surgery&#39;s risk of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> Data from other studies performed in individual hospitals have shown very varied gross incidences of surgical infection after the implantation of prostheses&#44; between 1&#46;25&#37; and 8&#46;2&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The information reported in Latin American hospitals is scarce&#46; In Chile&#44; a report from 2007 showed a 2&#46;5&#37; incidence in a period of 5 years for hip arthroplasties&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a> A report from Brazil mentions 34 infected knee prostheses over a year in a 150 active-bed hospital&#44; however&#44; they did not specify the amount of procedures undertaken in a year&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">25</span></a> There are only reports of retrospective studies in Mexico with joint infection figures from 4&#46;2&#37; to 8&#46;4&#37;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">7&#44;26</span></a> in the <span class="elsevierStyleItalic">Instituto Nacional de Rehabilitaci&#243;n</span> and in the Mexican Social Security Institute&#44; respectively&#44; which do not provide a complete overview of what is happening in Mexico&#44; even though the studies were performed in 2 high speciality centres in our country&#44; with wide experience in prosthesis placement&#46; Therefore&#44; creating a cohort enables long term follow up of the cases included&#44; which offers a broader view of the presentation time and possible factors that might influence a disease presenting in an institution and enable an evaluation of its applicability to other areas of our country&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">27</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In this study we observed that the general cumulative incidence for both procedures during the first year of follow-up in these patients is below 2&#37;&#58; very much below that reported by other Latin American hospitals and very similar to those reported by hospitals in the United States&#46; However&#44; it is slightly more for hip procedures&#46; Acute prosthetic infections were the most frequently encountered in terms of time of presentation at 83&#37;&#46; Reports from other series show that the clinical presentation of infections can vary according to the classification &#40;acute or chronic&#41;&#44; since some reports used the classification by Tsukuyama et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">28</span></a> and others that of Del Pozo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">29</span></a> which makes accurate comparison in terms of time of presentation impossible&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Different microorganisms were found in this study that were integral to the normal skin flora as well as from the digestive tract&#44; even with no history of gastroenterological infection in the period during which the infection was diagnosed&#44; and therefore there might well have been a wound infection due to faecal contamination&#46; The case of prosthetic infection by <span class="elsevierStyleItalic">Pasteurella stomatis</span> had no history of living with animals&#44; and it was not possible to assess the likely entry route of the microorganism&#46; On assessment of the history of the patients with acute hip infections&#44; 50&#37; had been treated by previous surgical procedures or after the prosthesis placement&#44; therefore having had previous surgery or later manipulation might have influenced development of the periprosthetic infection&#46; It was observed in another study that hip prosthesis infections are associated with the presence of haematoma due to a previous neck of femur fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">30</span></a> However&#44; prostheses were indicated in our study due to chronic arthropathy rather than fractures secondary to trauma&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">It is striking that the antibiotic administration time was disproportionate in most of the patients&#44; compared to that routinely recommended&#44; since preoperative antibiotic prophylaxis should be given within 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min before beginning the surgical incision<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">31&#8211;34</span></a> and the antibiotic of choice should be a first or second generation cephalosporin&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">34&#8211;37</span></a> It is poor practice to leave the responsibility to the anaesthetist&#44; since they cannot achieve optimal administration as they receive and assess patients for anaesthesia&#46; Therefore&#44; we suggest that it should be given when the patient enters the operating room&#44; and thus ensure the necessary time for the drug to reach a good concentration in the tissues&#46; In order to ensure the appropriate concentration of the antimicrobial agent&#44; both in serum and tissue&#44; it is recommended to repeat the intraoperative dose for procedures that exceed 2 half-lives of the drug&#44; or for procedures with excessive blood loss &#40;1500<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">38</span></a> In general&#44; repeating the antimicrobial dose after wound closure is not necessary and might increase antimicrobial resistance selection&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">39&#8211;43</span></a> In a systematic review of randomised trials&#44; there was no difference in the surgical wound infection rate in patients who received a single dose of antibiotic compared to multiple dose regimens&#44; given for less or more than 24<span class="elsevierStyleHsp" style=""></span>h &#40;OR 1&#46;04&#44; of 95&#37;&#58; &#46;86&#8211;1&#46;25&#41;&#46; Therefore&#44; giving antibiotics for longer than 24<span class="elsevierStyleHsp" style=""></span>h is not necessary&#44; as observed in this study where the patients received postoperative antibiotics for a median of 12 days&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">40</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Comorbidities presented in half the patients treated with surgical procedures&#59; arterial hypertension was the most frequently reported&#46; It is striking that the great majority of the patients did not apparently have immunosuppressive disease&#44; which might be a benefit for this cohort&#46; However&#44; it might be that there were patients in this series with systemic rheumatological diseases predominating in the joints and with little expression in other organs&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">One death was documented&#44; that was not associated with the infectious process&#44; since it was secondary to an acute myocardial infarction&#46; In this regard&#44; Aynardi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">44</span></a> observed in a retrospective study that &#46;46&#37; of the patients treated in one of 8261 hip arthroplasty procedures died within 90 days and that the main cause of death was cardiovascular in 32&#37; and&#44; of these&#44; 26&#37; were secondary to a myocardial infarction&#46; Therefore appropriate preoperative assessment is recommended to identify the cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">44</span></a> This was undertaken in the <span class="elsevierStyleItalic">Instituto Nacional de Rehabilitaci&#243;n</span>&#44; although not systematically&#44; since the patients might have brought assessments from other care centres&#44; and therefore the assessment was not homogeneous&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">It can be seen that the infection rate in both procedures is within that recommended by the international standards&#44; which is due to the good organisation programme of the hip and knee joint reconstruction department&#44; which has been perfected over time&#44; since patients are comprehensively assessed and the procedure is considered purely elective surgery that is not performed if there is any potential risk for the patients&#46; It is always ensured that all the material is ready prior to commencing the procedure&#59; if not&#44; the surgery does not go ahead&#46; It is important to mention that the staff who participate directly in the operation are experienced and that an attending physician is present&#59; this ensures that the procedure is undertaken safely and appropriately&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The infections found were treated with debridement and antibiotic therapy targeted towards microbiological isolation and no prosthesis has had to be removed in the follow-up period to date&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The treatment of prosthetic infections is complex and requires strict collaboration between orthopaedic surgeons and infectious disease specialists&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a> Protocolising the clinical treatment of this disease and undertaking clinical trials is made difficult due to the great variation in clinical circumstances&#44; the difficulty in gathering sufficiently numerous series&#44; and the need for prolonged follow-up&#46; Beyond selected case series&#44; we have few data on how prosthetic infections are treated overall in our country&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">7&#44;8</span></a> Therefore studies are required on medical personnel&#39;s knowledge of this disease&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">This is the first prospective study undertaken in a specialist prosthesis placement centre in Mexico with encouraging results&#46; The results of this study offer an overall view of hip and knee prosthesis infections in our hospital&#44; by analysing epidemiological aspects&#44; risk factors&#44; clinical presentation and the therapeutic treatment of cases&#44; and providing an outline of the facts of the problem&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">The incidence of hip and knee joint prosthesis infection in the <span class="elsevierStyleItalic">Instituto Nacional de Rehabilitaci&#243;n</span> is within the recommended parameters in the first year of follow-up&#46; The organisational practice and surgical techniques influence the good results obtained&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0205" class="elsevierStylePara elsevierViewall">This manuscript had no source of financing&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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          "identificador" => "sec0030"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conclusions"
        ]
        9 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Funding"
        ]
        10 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflict of interest"
        ]
        11 => array:2 [
          "identificador" => "xack334569"
          "titulo" => "Acknowledgements"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-10-28"
    "fechaAceptado" => "2016-10-31"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec954563"
          "palabras" => array:3 [
            0 => "Prosthesis-related infections"
            1 => "Incidence"
            2 => "Bacteria"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec954564"
          "palabras" => array:3 [
            0 => "Infecci&#243;n relacionada con pr&#243;tesis"
            1 => "Incidencia"
            2 => "Bacteria"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hip and knee prosthetic replacements have proven to be the most appropriate treatment in the joints that do not benefit from medical or arthroscopic interventions&#59; however&#44; infections are the most feared complication&#46; It is recommended that the incidence of infection should not exceed 2&#37;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was an observational&#44; prospective&#44; longitudinal and observational study conducted in patients fitted with a prosthetic joint from August 2011 to July 2012&#46; Patients were followed up pre and post-surgery for one year to identify a prosthetic infection&#44; diagnosed using international parameters&#46; We calculated the incidence of prosthetic infection&#44; as well as the incidence density&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 339 patients &#40;179 hip and 160 knee&#41; were included&#46; Variations in the time of pre-operative antibiotics&#8217; administration were observed&#46; Six prosthetic infections were identified with an incidence rate of 1&#46;79&#47;339 arthroplasties&#44; 2&#46;2&#47;179 hip procedures&#44; and 1&#46;25&#47;160 knee arthroplasties&#46; An incidence density of 0&#46;02&#47;year for hip arthroplasties and 0&#46;11&#47;year for knee procedures was identified&#46; There were 4 infections of hip and 2 of knee&#46; Five infections were acute and one chronic&#46; The isolated microorganisms were <span class="elsevierStyleItalic">Enterococcus faecalis</span>&#44; <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> &#40;2&#41;&#44; <span class="elsevierStyleItalic">Streptococcus mitis</span>&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Pasteurella stomatis</span>&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The incidence of prosthetic joint infection in the first year of follow-up at our centre is within the recommended parameters&#46; Surgical techniques and organisational practices influence the results&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las artroplastias de cadera y rodilla han demostrado ser el tratamiento &#243;ptimo para las articulaciones que no se benefician de intervenciones m&#233;dicas o artrosc&#243;picas&#59; sin embargo&#44; la infecci&#243;n de la pr&#243;tesis articular es la complicaci&#243;n m&#225;s temida&#46; Se estima que la incidencia de las infecciones no debe exceder del 2&#37;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo un estudio observacional&#44; longitudinal&#44; prospectivo en pacientes tratados mediante pr&#243;tesis articular de agosto de 2011 a julio de 2012&#46; Se les realiz&#243; un seguimiento pre- y posquir&#250;rgico anual para identificar un proceso infeccioso articular&#46; Se reconocieron las infecciones de pr&#243;tesis utilizando los est&#225;ndares internacionales acostumbrados&#46; Se calcul&#243; la incidencia de infecciones de pr&#243;tesis&#44; as&#237; como la densidad de incidencia&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 339 pacientes &#40;179 de cadera y 160 de rodilla&#41;&#46; Se observaron alteraciones en la hora de aplicaci&#243;n de antibi&#243;ticos preoperatorios&#46; Se identificaron 6 infecciones prot&#233;sicas&#44; con una tasa de incidencia de 1&#46;79&#47;339 artroplastias&#44; de 2&#46;2&#47;179 para cadera y de 1&#46;25&#47;160 para rodilla&#46; Una densidad de incidencia de 0&#46;02&#47;a&#241;o para cadera y de 0&#46;11&#47;a&#241;o para rodilla&#46; Hubo 4 infecciones de cadera y 2 de rodilla&#44; 5 de ellas infecciones agudas y una cr&#243;nica&#46; Los microorganismos aislados fueron <span class="elsevierStyleItalic">E&#46; faecalis</span>&#44; <span class="elsevierStyleItalic">S&#46; epidermidis</span> &#40;2&#41;&#44; <span class="elsevierStyleItalic">S&#46; mitis</span>&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> y <span class="elsevierStyleItalic">P&#46; stomatis</span>&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La incidencia de infecci&#243;n de pr&#243;tesis articular de cadera y rodilla en nuestro centro est&#225; dentro de los par&#225;metros recomendados dentro del primer a&#241;o de seguimiento&#46; Las pr&#225;cticas organizacionales y t&#233;cnicas quir&#250;rgicas influyen en los buenos resultados&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Franco-Cendejas R&#44; Contreras-C&#243;rdova EL&#44; Mondrag&#243;n-Eguiluz JA&#44; Vanegas-Rodr&#237;guez ES&#44; Ilizaliturri-S&#225;nchez VM&#44; Galindo-Fraga A&#46; Incidencia de infecciones prot&#233;sicas primarias de cadera y rodilla en un centro de la Ciudad de M&#233;xico&#46; Cir Cir&#46; 2017&#59;85&#58;485&#8211;492&#46;</p>"
      ]
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hip <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>179&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Knee <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Female</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">114 &#40;63&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">115 &#40;71&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Median age &#40;min&#8211;max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;21&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;26&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Educational level</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Illiterate <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;17&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Comorbidities n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Arterial hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;64&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;69&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;21&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;24&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;2&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rheumatological disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;14&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Smoking</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;35&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;18&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Median body mass index &#40;min&#8211;max&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;2 &#40;15&#46;9&#8211;39&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;19&#46;3&#8211;46&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ASA</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">risk n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">167 &#40;93&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">154 &#40;96&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;29&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;21&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">106 &#40;63&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">108 &#40;70&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;6&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Reason for placement</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">140 &#40;78&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">159 &#40;99&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fracture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;7&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Demographic variables of the patients&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hip <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>179&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Knee <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Completed 12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">166&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Follow-up time in days &#40;range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">402 &#40;365&#8211;740&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">390 &#40;365&#8211;728&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1676347.png"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Post hospital follow-up for at least one year&#46;</p>"
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        "etiqueta" => "Table 3"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time of presentation of the infection &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of prosthesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time of antibiotic administration prior to incision &#40;minutes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery time &#40;minutes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">220&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Previous surgery 1 week before &#40;soft tissue release&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Previous surgery &#40;hip fracture 5 weeks before&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Later surgery &#40;periprosthetic fracture at 48<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Knee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rheumatoid arthritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death due to ischaemic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Knee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">187&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Description of the relevant characteristics associated with the infectious process in the 6 patients with prosthetic infection&#46;</p>"
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        "etiqueta" => "Table 4"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hip <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>175&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Knee <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute infections &#40;&#60;3 months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Delayed infections &#40;3 months&#8211;2 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Causative microorganisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Enterococcus faecalis&#44; Staphylococcus epidermidis</span> &#40;2&#41; <span class="elsevierStyleItalic">Streptococcus mitis&#44; Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Pasteurella stomatis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Types of prosthetic infections and microorganisms involved&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:45 [
            0 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk factors for surgical-site infection following primary total knee arthroplasty"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "B&#46; Minnema"
                            1 => "M&#46; Vearncombe"
                            2 => "A&#46; Augustin"
                            3 => "J&#46; Gollish"
                            4 => "A&#46;E&#46; Simor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/502425"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Control Hosp Epidemiol"
                        "fecha" => "2004"
                        "volumen" => "25"
                        "paginaInicial" => "477"
                        "paginaFinal" => "480"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15242195"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prosthetic joint infections&#58; update in diagnosis and treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Trampuz"
                            1 => "W&#46; Zimmerli"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "2005/17/smw-10934"
                      "Revista" => array:7 [
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                        "fecha" => "2005"
                        "volumen" => "135"
                        "paginaInicial" => "243"
                        "paginaFinal" => "251"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15965826"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0091674912002564"
                          "estado" => "S300"
                          "issn" => "00916749"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46; Kurtz"
                            1 => "K&#46; Ong"
                            2 => "E&#46; Lau"
                            3 => "F&#46; Mowat"
                            4 => "M&#46; Halpern"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2106/JBJS.F.00222"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Bone Joint Surg Am"
                        "fecha" => "2007"
                        "volumen" => "89"
                        "paginaInicial" => "780"
                        "paginaFinal" => "785"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17403800"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Long-term followup of nonmodular total knee replacements"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46;M&#46; Keating"
                            1 => "J&#46;B&#46; Meding"
                            2 => "P&#46;M&#46; Faris"
                            3 => "M&#46;A&#46; Ritter"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Orthop Relat Res"
                        "fecha" => "2002"
                        "volumen" => "404"
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                        "paginaFinal" => "39"
                      ]
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                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibiotic treatment of gram-positive bone and joint infections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46;S&#46; Darley"
                            1 => "A&#46;P&#46; MacGowan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/jac/dkh191"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2004"
                        "volumen" => "53"
                        "paginaInicial" => "928"
                        "paginaFinal" => "935"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15117932"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infection and arthritis&#46; Infection of prosthetic joints"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Lidgren"
                            1 => "K&#46; Knutson"
                            2 => "A&#46; Stefansdottir"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Best Pract Res Clin Rheumatol"
                        "fecha" => "2003"
                        "volumen" => "17"
                        "paginaInicial" => "209"
                        "paginaFinal" => "218"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12787522"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
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Article information
ISSN: 24440507
Original language: English
DOI:10.1016/j.circen.2016.10.010
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