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Revista Española de Cirugía Ortopédica y Traumatología (English Edition)
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Original Article
Periprosthetic infection in elderly patients treated with hemiarthroplasty of the hip following intracapsular fracture. Should be use antibiotic-loaded bone cement?
Infección periprótesica en pacientes ancianos tratados mediante hemiartroplastia de cadera tras fractura intracapsular. ¿Debemos usar cementación con antibiótico?
D. Aedo-Martína,b,
Corresponding author
daniaedo@gmail.com

Corresponding author.
, D. Crego-Vitaa, R. García-Cañasa, A. Espigares-Correaa, C. Sánchez-Pérezc, F.J. Areta-Jiméneza
a Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Central de la Defensa Gómez Ulla, Madrid, Spain
b Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Henares, Madrid, Spain
c Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prosthetic infections are a rare but potentially devastating complication&#46; The rate of infection after a primary hip arthroplasty is between 1&#37; and 2&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> but is much more daunting when we refer to elderly patients with hip fractures&#44; where rates rise to between 1&#46;7&#37; and 7&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This involves high socioeconomic costs<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and raised morbimortality&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Antibiotic-loaded bone cements have been used both as a treatment and as prophylaxis in prosthetic infection&#46; Whilst their use has been well studied in elective primary arthoplasty&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> it has not been well documented in the prophylaxis of infection in partial prosthesis implantation in patients with a hip fracture&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The use of acrylic cements in orthopaedia dates back to the decade of the 1950&#8217;s when Sir John Charnley became interested in them&#44; but it was not until 1969 when investigation into their use as a vector for the release of antibiotic drugs in situ was started by Buccholz and Engelbrecht&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The interest in creating cements enriched with antibiotics is due to the difficulty in achieving effective levels of antibiotics in bone tissue&#44; because the pro-inflammatory conditions reduce blood flow and impede drug access&#44; although there is no real anatomical barrier&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Furthermore&#44; the bacteria in contact with the implants create adhesive barriers&#44; biofilms&#44; which prevent the penetration of the antibiotic and minimize its effect&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Antibiotic-loaded bone cements are of great value for the release of effective doses directly into the required area over a prolonged period&#44; which according to some studies is limited to the first 2 years&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This maximizes the concentrations of the antibiotic drug in the joint and minimises systemic exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The high rates of prosthetic infection after hemiarthroplasty detected in our centre have led us to contemplate other strategies in infection prophylaxis&#46; We decided to analyse the impact the introduction of antibiotic-loaded bone cement has had in our population&#44; with the hypothesis that its use&#44; combined with systemic prophylaxis would result in a protective factor&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Our main objective was to compare the rate of infection in patients with a hip fracture and who had been operated on for a hemiarthroplasty with antibiotic-loaded bone cement compared to those in whom no antibiotic-loaded bone cement had been used&#46; Our secondary objective was to analyse the different variables which could have had an impact on the development of infection&#44; to undertake a population analysis and a pilot cost study&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective descriptive study was conducted in the Universitario Central de la Defensa G&#243;mez Ulla of Madrid &#40;Spain&#41;&#46; Data was obtained from all of the patients who underwent hip hemiarthroplasty due to a subcapital fracture between 2011 and 2017 from their medical file &#40;written or digital in the Balmis &#174;&#44; electronic clinical history programme&#44; Hewlett Packard Espa&#241;ola&#44; SL&#41;&#46; Inclusion criteria considered any intracapsular fracture of the femur operated on with cemented arthroplasty &#40;bipolar or monopolar&#41;&#46; Exclusion criteria included pathological fractures and patients who died during the first 30 days following intervention&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All operations were performed by the same medical team and used the same surgical approach route &#40;direct lateral or Hardinge&#41;&#46; Preoperative parenteral prophylaxis was performed with 2<span class="elsevierStyleHsp" style=""></span>g of cefazolin one hour prior to the operation or 1<span class="elsevierStyleHsp" style=""></span>g of vancomycin if there was a contraindication or allergy to cephalosporins&#46; Three doses were administered after surgery of 1<span class="elsevierStyleHsp" style=""></span>g every 8<span class="elsevierStyleHsp" style=""></span>h for cefazolin or 2 doses of 1<span class="elsevierStyleHsp" style=""></span>g of vancomycin every 12<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The implanted prosthesis was a SAMO Multifit &#174; with a monopolar Ellitica &#174; head or bipolar SBA &#174; &#40;SAMO biomedical&#44; Italy&#41; head in all patients&#46; The cement used was CEMEX &#174; &#40;TECRAS SPA&#44; Italy&#41;&#44; an antibiotic-free cement with high viscosity mixed and applied with a cement gun and mixture without a vacuum system up until June 2013&#46; From that date onwards and until the end of the study &#40;December 2017&#41; the Palacos&#174; R<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G &#40;Heraeus Medical GmbH&#44; Germany&#41; cement was used&#44; with gentamycin &#40;&#46;5<span class="elsevierStyleHsp" style=""></span>g&#41; of high viscosity&#44; mixed using a vacuum system and applied with a pressure cement gun&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Data was collected retrospectively on age&#44; sex&#44; type of intracapsular hip fracture according to the Garden scale&#44; injurious mechanism &#40;low&#47;high energy&#41;&#44; form of transfer to emergency services &#40;walking&#44; taken by family members in a private vehicle&#44; taken by ambulance from home or by ambulance for another healthcare centre&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The presence or absence of previous risk factors for the development of infection was assessed &#40;inflammatory arthopathies&#44; immunosuppressant status&#44; diabetes mellitus type 1&#44; previous joint infection&#44; malnutrition&#44; malignant tumours o haemophilia&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The physical status of the patients was assessed using the <span class="elsevierStyleItalic">American Society of Anesthesiologists physical status scale</span> &#40;ASA&#41;&#44; ambulation ability was assessed using the <span class="elsevierStyleItalic">Functional Ambulation Category Score</span> &#40;FAC&#41; and degree of dependence for everyday life activities by the <span class="elsevierStyleItalic">Modified Barthel Functional Index</span>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The development of acute or late infection in both groups &#40;cemented with or without antibiotics&#41; was assessed and mean time until infection was diagnosed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Diagnosis of infection was approached according to the criteria reflected in the 21st anual meeting of the <span class="elsevierStyleItalic">Musculoskeletal Infection Society</span> in 2011 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Data were collected in a Microsoft Excel &#174; table anonymously and analysed with the SPSS &#174; version 15 statistical package &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; U&#46;S&#46;A&#46;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A pilot cost&#47;benefit study was also conducted&#44; comparing the cost of the products&#44; surgical interventions and length of stay in the hospital according to the standard DRG &#40;diagnosis related groups&#41; coding&#44; established by Order DEF&#47;2277&#47;2014&#44; of 28th November&#44; published in the Official State Bulletin &#40;BOE-A-2014-942&#41; which established the public prices for provision of healthcare services and activities in the Ministry of Defence area&#46; The price offered included&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Routine or special diagnostic and therapeutic tests&#44; which the patient was required to have prior to the procedure they were to be submitted to&#44; including&#44; when necessary&#44; the preoperative study&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">The costs derived from possible complications which could present over the whole healthcare process&#44; both in the preoperative phase and in the actual surgical and postoperative intervention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The necessary surgical reinterventions required by the patient&#44; provided they are always related to the process leading to admission&#44; resulting from poor surgical practice and taking place within a period not superior to 2 months&#44; counted from the day after hospital discharge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Medical treatment if required during the process&#44; or blood and blood products&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Healing treatments&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">f&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Food&#44; including parenteral and enteral nutrition&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">g&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Assistance by a specialised medical team&#59; nurses and auxiliary healthcare staff&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">h&#41;</span><p id="par0120" class="elsevierStylePara elsevierViewall">The use of an operating theatre and anaesthesia costs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">i&#41;</span><p id="par0125" class="elsevierStylePara elsevierViewall">The necessary expendable material and pre and postoperative controls&#44; including those of the outpatient regime&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">j&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Costs of days in the hospital in a shared room or a private room&#44; when due to the special circumstances of the patient this becomes necessary&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">k&#41;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Any necessary intensive care unit stays in hospital&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">l&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Revision check-ups that are necessary after hospital discharge&#44; with at least one consultation for each procedure&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0145" class="elsevierStylePara elsevierViewall">During the study period of 2191 days &#40;January 2011&#8211;January 2017&#41; a sample of 241 patients was obtained&#44; 94 of whom received antibiotic-loaded bone cement and 147 who did not&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Population clinical data &#40;age&#44; sex&#44; type of fracture according to Garden classification&#44; fracture mechanisms&#44; method of hospital transfer and the presence of risk factors for the development of infection&#41; are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">In the group which received cement without antibiotic only 38 patients &#40;25&#46;9&#37;&#41; presented with a history of medical risk for the development of infection &#40;inflammatory arthropathies&#44; immunosuppressant status&#44; diabetes mellitus type 1&#44; previous joint infection&#44; malignant tumours or haemophilia&#41;&#46; In the group which received antibiotic-loaded bone cement this percentage of patients was 39&#46;4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41;&#46; We also assessed the use of oral anticoagulants &#40;acenocumarol&#41;&#58; this was used in 18 &#40;7&#46;4&#37;&#41;&#59; 10 &#40;6&#46;8&#37;&#41; in the group of cement without antibiotic and 8 &#40;8&#46;5&#37;&#41; in the group with antibiotic-loaded bone cement&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The predominant ASA in both groups was 3 &#40;patient with severe but not incapacitating systemic disease&#41; in 127 patients &#40;52&#46;9&#37;&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Regarding the functional state of patients&#44; in both groups a FAC dependence of 4 predominated &#40;independent walking on flat ground&#44; but no stairs&#41;&#44; median and mode<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4 for both groups and a dependence on the Barthel scale with a median of 70 points in both groups &#40;moderate dependence&#41;&#44; cement without antibiotic mode<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#59; cement with antibiotic mode<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>80&#46; Mean ages were very similar in both groups&#58; around 85 years of age&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In the group which received antibiotic-loaded bone cement &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41; there were 8 infections &#40;8&#37;&#41; of which 4 were acute &#40;under 3 months&#41; and 4 late &#40;&#62;3 months&#41;&#46; In the group with cement without antibiotic &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>147&#41; there were 28 infections &#40;19&#37;&#41; of which 8 were acute and 20 late &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Between the 2 groups there were 14&#46;9&#37; of acute and late infections &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>36&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">The odds ratio &#40;OR&#41; was calculated showing a 55&#46;3&#37; reduction in the risk of developing late infection in the group who received cement with antibiotic &#40;95&#37; IC&#58; 6&#46;2&#8211;78&#46;7&#37;&#41; compared to those who did not receive cement with antibiotic &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0025&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The process of a partial prosthesis of the hip costs approximately 12&#44;665&#8364;&#44; and when there are complications there would be added costs of 11&#44;540&#46;45 &#8364; &#40;approximately 24&#44;205 &#8364; per patient in the case of acute infection or of 35&#44;746 &#8364; in the case of late infection due to the longer hospital stay and number of operations&#41;&#46; Bearing in mind that the PALACOS&#174; R<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G cement has an added cost of approximately 20&#8364; per unit compared to CEMEX&#174; cement without antibiotic&#44; the group treated with antibiotic-loaded bone cement cost a mean of 14&#44;127&#46;54 &#8364; per patient whilst the group with cement without antibiotic cost a mean of 17&#44;632&#46;81 &#8364; per patient&#46; These costs are approximate&#44; and are in keeping with the DRG of our centre&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Implant contamination most often occurs from direct spread during surgery&#44; direct spread through skin defects or from haematogenous spread&#46; The most common isolated germ is <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In their study Stef&#225;nsd&#243;ttir et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> reviewed deep infections in primary knee arthroplasty through the national Swedish register between 1986 and 2000&#44; and found that in acute&#44; subacute and late infections coagulate negative staphylococcus were the most prevalent &#40;35&#46;1&#37;&#41; and double as common as <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;18&#46;4&#37;&#41;&#44; which was the predominant pathogen in blood-borne infections&#46; This microbiological pattern changed considerably during the study period &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019&#41;&#58; the proportion of infections caused by <span class="elsevierStyleItalic">S&#46; aureus</span> fell from 46&#46;3&#37; in 1986&#8211;1990 to 27&#46;6&#37; between 1996 and 2000&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The use of antibiotic-loaded bone cements has been well studied in primary arthroplasty&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Engesaeter et al&#46; performed an analysis of 22&#44;170 primary hip arthroplasties through the Norwegian register between 1987 and 2001 and compared systemic antibiotic prophylaxis combined with the use of antibiotic-loaded bone cement to antibiotic prophylaxis alone in different administration guidelines&#46; The best results were obtained in the group which received intravenous prophylaxis and also cement with antibiotic&#58; systemic prophylaxis alone had 1&#46;4 times more revision surgery &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; 1&#46;3 times more revision surgery for aseptic loosening &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41; and 1&#46;8 times more rates of infection &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Furthermore&#44; Jiranek et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> carried out an in-depth analysis of the current state of use of antibiotic-loaded bone cements in primary arthroplasty and recommended its prophylactic use against infection only in patients who had a high risk of infection&#58; i&#46;e&#46; those patients with associated factors such as inflammatory arthropathies &#40;rheumatoid arthritis&#44; lupus&#41;&#44; immunosuppressant status&#44; diabetes mellitus type 1&#44; prior joint infection&#44; malnutrition&#44; malignant tumours or haemophilia&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The use of antibiotic-loaded bone cements in hemiarthroplasty cases after a fracture is not well documented in scientific literature&#46; The main use of hemiarthroplasty of the hip is restricted as the treatment of choice in intracapsular fractures in elderly patients&#46; We should consider that the prototype patient is not the same as in an elective prosthesis&#46; These are elderly patients with many comorbidities&#44; which drastically reduce their life expectancy<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and increase their possibilities of suffering from a prosthetic infection up to 4 times more than in an elective arthroplasty&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> but who also have presented with a traumatic event which in itself affects their survival enormously&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Mortality after a hip hemiarthroplasty is around 10&#8211;40&#37; in the first year&#44; often linked to an infection&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Infection rates after the implantation of a partial hip prosthesis are between 1&#46;7&#37; and 7&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In our study&#44; this figure was much higher&#58; between acute and late infections the rate was 14&#46;9&#37;&#46; We believe that this rate&#44; higher than that identified by other studies&#44; could be due to the old age of the population treated by our hospital &#40;78&#46;42&#37; of our sample were over 80 years of age&#41;&#46; Also&#44; if we refer to the definition of a fragile elderly person&#44; our patients met with many of the criteria included in this group &#40;advanced age&#44; moderate dependence measured by the Barthel scale&#44; changes to mobility and balanced measured through the FAC scale&#44; medical&#47;comorbidity status measured through the ASA scale&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The use of cemented implants may slightly increase time in surgery and bleeding&#44; although it is not of clinical significance since there is no increase in morbimortality&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> but it seems clear that the use of cement reduce pain and improves the patient&#8217;s mobility after surgery&#44; without a significant increase in complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">In a bibliographic review of 37 articles obtained from the data bases of MedLine&#44; PubMed and Cochrane&#44; Noailles et al&#46; Identified the risk factors for the development of a surgical infection after hemiarthroplasty and possible methods of prevention and they recommended the use of antibiotic-loaded bone cement&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The comorbidity of the patient &#40;obesity&#44; liver disease&#44; advanced age&#41;&#44; the intraoperative conditions &#40;inexperienced surgeons&#44; prolonged time of surgery or cementless implants&#41; and postoperative management &#40;prolonged hospitalisation&#44; haematoma&#44; prolonged use of drainage or repeated use of vesicle catheters&#41; were identified as the risk factors in the development of surgical infection&#46; Recently&#44; Crego et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> demonstrated that functional ASA classification and advanced age are independent factors in obtaining poorer results since they increase complications and mortality after surgery in elderly patients with hip fractures&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Sanz-Ruiz et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> in a comparative study with 2518 patients operated on for total or partial prosthesis of the hip and of the knee&#44; analysed the relative risk reduction of a prosthetic infection when using antibiotic-loaded bone cement vs&#46; cement without antibiotic and specifically 72&#46;6&#37; in the case of the hip arthroplasty &#40;partial or total&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019&#41;&#46; Subsequently&#44; in cost calculation&#44; the use of antibiotic-loaded bone cement resulted in a saving of 1123&#46;846 &#8364; &#40;992 &#8364; per patient&#41;&#44; as the rate of infections dropped&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">In our study a 55&#46;3&#37; drop in the risk of developing late infection was observed in the group which received antibiotic-loaded bone cement &#40;95&#37; CI&#58; 6&#46;2&#8211;78&#46;7&#37;&#41; compared to those who had not received antibiotic-loaded bone cement &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0025&#41;&#46; The group treated with antibiotic-loaded bone cement cost a mean of 14&#44;127&#46;54 &#8364; per patient&#44; whilst the group with cement without antibiotic cost a mean of 17&#44;632&#46;81 &#8364; per patient&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Some of the possible problems which could present with the use of antibiotic-loaded bone cements according to its detractors would be the development of bacterial resistance&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> because of the exposure of subinhibitory concentrations of antibiotics prolonged over time&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> A source of concern is also whether the mechanical properties of the cement<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> may be affected&#46; With regards to the toxicity or allergies from use&#44; these have very rarely been reported in publications and isolated reports have referred to hypersensitivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> In our study we did not find any adverse effects or allergies to the use of antibiotic-loaded bone cement&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Recently&#44; Sprowson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> conducted a quasi-randomised study to compare the effectiveness of cements with dual synergistic action antibiotics &#40;1<span class="elsevierStyleHsp" style=""></span>g clindamycin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>g de gentamicin&#41; vs&#46; plain &#40;&#46;5<span class="elsevierStyleHsp" style=""></span>g de gentamicin&#41; in patients with intracapsular hip fracture&#58; the result was a reduction in the rate of surgical infection without any increase in complications&#46; However&#44; further studies are necessary to determine optimum doses of antibiotics and their effect on the mechanical characteristics of the cement&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">It is striking that&#44; despite being in favour of the use of antibiotic-loaded bone cement for the prevention of infections the Food and Drug Administration has only approved its use in second time reimplantation in a replacement prosthesis which had been previously infected&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;30</span></a> We should also take into account the epidemiological peculiarities and the different costs of marketing antibiotic-loaded bone cements in other countries such as the United States&#44; in what Sanz-Ruiz describes as &#8220;the transatlantic paradox&#8221; where results cannot be extrapolated&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Our study has several imitations which should be mentioned&#46; On the one hand&#44; the fact it is retrospective in nature and the low sample number of patients&#46; Also there is an imbalance between the group who received cement without antibiotic &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>147&#41; vs&#46; those with antibiotic &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41; and the fact that the antibiotic came from two different manufacturers&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0245" class="elsevierStylePara elsevierViewall">The strength of our study resides in the demonstration of the use of antibiotic-loaded bone cement as a protective factor in the development of late surgical infection&#58; it is one of the few studies that takes into account the peculiarities of the population with hip fracture and also encompasses an epidemiological study of the patients who were hospitalised as a result&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Although our cost study was a pilot study and is not definitive&#44; it is highly illustrative of the major benefit obtained with a simple cost increase of scarcely 20&#8364; per patient&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Given the well-known high costs and devastating repercussions of a prosthetic infection&#44; the research team would recommend the use of antibiotic-loaded bone cement as prophylaxis in primary prosthetic surgery in patients with intracapsular hip fracture&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            0 => "Infection"
            1 => "Antibiotic-loaded bone cement"
            2 => "Hip hemiarthroplasty"
            3 => "Hip fracture"
            4 => "Prophylaxis"
            5 => "Cost saving"
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          "clase" => "keyword"
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          "palabras" => array:6 [
            0 => "Infecci&#243;n"
            1 => "Cemento con antibi&#243;tico"
            2 => "Hemiartroplastia cadera"
            3 => "Fractura cadera"
            4 => "Profilaxis"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Prosthetic infections are a potentially devastating complication&#44; especially in elderly patients&#46; Antibiotic-loaded bone cement has been used both as a treatment and prophylaxis in prosthetic infection&#44; and its use is not well documented in the prophylaxis of infection in patients who have suffered a hip fracture&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A retrospective descriptive was performed&#46; The data were obtained from all the patients who underwent hip hemiarthroplasty due to a subcapital fracture between 2011 and 2017 &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>241&#41;&#46; An epidemiological study of the patients studied was carried out&#46; We analysed the incidence of periprosthetic infection in the groups treated with cement without antibiotic and antibiotic-loaded bone cement&#44; as well as the protective effect of the antibiotic-loaded bone cement&#46; At the same time&#44; a pilot cost analysis study was carried out&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">In the group that received antibiotic-loaded bone cement &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41; there were 8 infections &#40;8&#37;&#41;&#44; while in the group with cement without antibiotic &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>147&#41; there were 28 infections &#40;19&#37;&#41;&#46; The odds ratio &#40;OR&#41; was calculated&#44; showing a 55&#46;3&#37; reduction in the risk of developing late infection in the group that received cement with antibiotic &#40;95&#37; CI&#58; 6&#46;2&#8211;78&#46;7 &#37;&#41; &#40;P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0025&#41;&#46; The use of antibiotic-loaded bone cement led to significant cost savings per patient&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The use of antibiotic-loaded bone cement is a protective factor in the development of late infection after hip hemiarthroplasty surgery in elderly patients with hip fracture&#46;</p></span>"
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          1 => array:2 [
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            "titulo" => "Material"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Las infecciones prot&#233;sicas son una complicaci&#243;n potencialmente devastadora&#44; m&#225;s a&#250;n en pacientes ancianos&#46; Los cementos con antibi&#243;tico han sido usados tanto como tratamiento como profilaxis en la infecci&#243;n prot&#233;sica&#44; no encontr&#225;ndose bien documentado su uso en la profilaxis de la infecci&#243;n en la cirug&#237;a hemiartroplastia en pacientes que han sufrido una fractura de cadera&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo donde se obtuvieron datos de todos los pacientes intervenidos mediante hemiartroplastia de cadera por fractura subcapital entre los a&#241;os 2011 y 2017 &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>241&#41;&#46; Se realiz&#243; un estudio epidemiol&#243;gico de los pacientes estudiados&#46; Se analiz&#243; la incidencia de infecci&#243;n periprot&#233;sica en los grupos tratados con cemento sin antibi&#243;tico y con antibi&#243;tico&#44; as&#237; como el efecto protector del mismo&#46; A su vez se realiz&#243; an&#225;lisis de costes piloto&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">En el grupo que recibi&#243; cemento con antibi&#243;tico &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41; se produjeron 8 infecciones &#40;8&#37;&#41;&#44; mientras que en el grupo con cemento sin antibi&#243;tico &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>147&#41; se produjeron 28 infecciones &#40;19&#37;&#41;&#46; Se realiz&#243; el c&#225;lculo de odds ratio &#40;OR&#41; observ&#225;ndose un 55&#46;3&#37; de disminuci&#243;n de riesgo de desarrollar infecci&#243;n tard&#237;a en el grupo que recibi&#243; cemento con antibi&#243;tico &#40;IC 95&#37;&#58; 6&#44;2&#8211;78&#44;7&#37;&#41; &#40;P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0025&#41;&#46; El uso de cemento con antibi&#243;tico conllev&#243; un importante ahorro de costes por paciente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El uso de cementos con antibi&#243;tico resulta un factor protector en el desarrollo de infecci&#243;n tard&#237;a en hemiartroplastia de cadera en pacientes ancianos con fractura de cadera&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Aedo-Mart&#237;n D&#44; Crego-Vita D&#44; Garc&#237;a-Ca&#241;as R&#44; Espigares-Correa A&#44; S&#225;nchez-P&#233;rez C&#44; Areta-Jim&#233;nez FJ&#46; Infecci&#243;n peripr&#243;tesica en pacientes ancianos tratados mediante hemiartroplastia de cadera tras fractura intracapsular&#46; &#191;Debemos usar cementaci&#243;n con antibi&#243;tico&#63; Rev Esp Cir Ortop Traumatol&#46; 2020&#59;64&#58;28&#8211;34&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Comparison in the development of periprosthetic infection with the use or non use of antibiotic-loaded bone cement&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t">Musculoskeletal Infection Society prosthetic infection criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Fistulous tract connected to the prosthesis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Pathogen isolated in culture in at least two different tissues or fluids&#44; obtained from the prosthetised joint</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Four of the following six criteria&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Elevated erythrocyte sedimentation &#40;ESR&#41; or elevated C reactive protein &#40;CRP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Elevated synovial white blood cell count&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Percentage of neutrophils elevated in synovial fluid &#40;PMN&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presence of pus in affected joint&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Isolation of a microorganism in a periprosthetic material or fluid culture&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Over five neutrophils per field in five fields after histological analyses of periprosthetic tissue&nbsp;\t\t\t\t\t\t\n
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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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cement without antibiotic &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>147&#41; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cement with antibiotic &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>241&#41; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Man&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;30&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71 &#40;29&#46;46&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105 &#40;71&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65 &#40;69&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">170 &#40;70&#46;54&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8804;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;18&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;26&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52 &#40;21&#46;58&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120 &#40;81&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;73&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">189 &#40;78&#46;42&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Garden&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;10&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;5&#46;81&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;11&#46;20&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;37&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82 &#40;34&#46;02&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;52&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 &#40;43&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">118 &#40;48&#46;96&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mechanism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High energy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;&#46;41&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low energy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">146 &#40;99&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">240 &#40;99&#46;59&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Walking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;2&#46;90&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arrival at emergency department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brought by family members&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;&#46;83&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ambulance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95 &#40;64&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75 &#40;79&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">170 &#40;70&#46;54&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brought from other centre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;13&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;25&#46;73&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History of risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;25&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;39&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75 &#40;31&#46;12&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">109 &#40;74&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">57 &#40;60&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166 &#40;68&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#44;2&#8211;3&#93;Infection</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Infection rate &#40;median days&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cement with antibiotic &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cement without antibiotic &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>147&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>241&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">205&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Acute i&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Late i&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cement with antibiotic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cement without antibiotic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Risk factors for prosthetic joint infection&#58; case-control study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46;F&#46; Berbari"
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                            2 => "M&#46;C&#46; Duffy"
                            3 => "J&#46;M&#46; Steckelberg"
                            4 => "D&#46;M&#46; Ilstrup"
                            5 => "W&#46;S&#46; Harmsen"
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                    0 => array:2 [
                      "doi" => "10.1086/514991"
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                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "1998"
                        "volumen" => "27"
                        "paginaInicial" => "1247"
                        "paginaFinal" => "1254"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9827278"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "What are the risk factors for post-operative infection after hip hemiarthroplasty&#63; Systematic review of literature"
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                          "autores" => array:5 [
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                            2 => "A&#46; Chalopin"
                            3 => "P&#46;M&#46; Longis"
                            4 => "F&#46; Gouin"
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                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int Orthop"
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                        "paginaFinal" => "6"
                        "itemHostRev" => array:3 [
                          "pii" => "S0140673617333044"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Cost of infection after surgery for intracapsular fracture of the femoral neck"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;D&#46; Wijeratna"
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                            2 => "M&#46;J&#46; Porteous"
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                    0 => array:2 [
                      "doi" => "10.1308/003588415X14181254788845"
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                        "tituloSerie" => "Ann R Coll Surg Engl"
                        "fecha" => "2015"
                        "volumen" => "97"
                        "paginaInicial" => "283"
                        "paginaFinal" => "286"
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                          0 => array:2 [
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                    0 => array:2 [
                      "doi" => "10.1080/00016470310018135"
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                        "tituloSerie" => "Acta Orthop Scand"
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                        "volumen" => "74"
                        "numero" => "Dec"
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                      "titulo" => "Cost-effectiveness of antibiotic-impregnated bone cement used in primary total hip arthroplasty"
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                            3 => "O&#46; Furnes"
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Bone Joint Surg Am"
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Article information
ISSN: 19888856
Original language: English
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