A protocol for periprosthetic joint infections from the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands.

Periprosthetic joint infection (PJI) is a devastating complication of joint arthroplasty surgery. Treatment success depends on accurate diagnostics, adequate surgical experience and interdisciplinary consultation between orthopedic surgeons, plastic surgeons, infectious disease specialists and medical microbiologists. For this purpose, we initiated the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands in 2014. The establishment of a mutual diagnostic and treatment protocol for PJI in our region has enabled mutual understanding, has supported agreement on how to treat specific patients, and has led to clarity for smaller hospitals in our region for when to refer patients without jeopardizing important initial treatment locally. Furthermore, a mutual PJI patient database has enabled the improvement of our protocol, based on medicine-based evidence from our scientific data. In this paper we describe our NINJA protocol.Level of evidence: III.

[A motorcyclist with hematomas and tingling in his leg]. / Motorrijder met hematomen en tintelingen in het been.

A 30-year-old man presented with recurrent hematomas and tingling in his left leg, caused by a large femoral neck osteochondroma that induced multiple muscle ruptures and compressed the ischiadic nerve. There were no radiological signs of malignant transformation and symptoms disappeared without intervention. Hence, we chose a 'wait and see' approach instead of surgical removal of the osteochondroma.

[A motorcyclist with hematomas and tingling in his leg]. / Motorrijder met hematomen en tintelingen in het been.

A 30-year-old man presented with recurrent hematomas and tingling in his left leg, caused by a large femoral neck osteochondroma that induced multiple muscle ruptures and compressed the ischiadic nerve. There were no radiological signs of malignant transformation and symptoms disappeared without intervention. Hence, we chose a 'wait and see' approach instead of surgical removal of the osteochondroma.

The design of a randomised controlled trial to evaluate the (cost-) effectiveness of the posterolateral versus the direct anterior approach for THA (POLADA - trial).

BACKGROUND: Total hip arthroplasty (THA) is one of the most successful orthopaedic procedures. Because of the increasing number of THAs, a growing demand for faster recovery and a greater emphasis on cost-effectiveness, minimally invasive THAs have been introduced in the last decades. The direct anterior approach is a minimally invasive, tissue-sparing approach in which intermuscular planes are used. Theoretically, this approach should result in a faster recovery of physical functioning and higher health-related quality of life. METHODS/DESIGN: A randomised controlled trial will be performed. Patients will be randomly allocated to undergo THA by means of the anterior or posterolateral approach. Both the intervention and control group will consist of two subgroups: 1) patients with a good bone stock who will receive an uncemented femoral stem, and 2) patients with a poor bone stock who will receive a cemented femoral stem. Patients between 18 and 90 years with primary or secondary osteoarthritis will be included. Physical functioning and health-related quality of life will be assessed by means of questionnaires. Additionally, performance based tests will be performed to objectively assess the physical functioning. Cost-effectiveness will be assessed by obtaining data on medical costs in and outside the hospital and other nonmedical costs. Measurements will take place preoperatively, two and six weeks, three months and one year postoperatively. DISCUSSION: There is some evidence that the anterior approach results in reduced tissue damage and faster recovery in the direct postoperative period, compared to the posterolateral approach. However, there is still a lack of well-designed studies that have confirmed the better outcomes and cost-effectiveness of the anterior approach. Therefore, the purpose of this study is to assess the physical functioning, health related quality of life and the cost-effectiveness of the anterior approach, compared to the conventional posterolateral approach. TRIAL REGISTRATION: Netherlands Trial Registry, number 5343 (registration date April 12, 2015).

Evaluation of measures to decrease intra-operative bacterial contamination in orthopaedic implant surgery.

The aim of this study was to evaluate whether behavioural and systemic measures will decrease intra-operative contamination during total hip or knee replacements. The influence of these measures on subsequent prolonged wound discharge, superficial surgical site infection and deep periprosthetic infection was also investigated during an 18-month follow-up period. Four swabs were taken from instruments at the beginning and end of the procedure for 207 procedures. Removed bone material (acetabulum and femur in case of the hip joint; femur and tibia in case of the knee joint) was also tested for contamination. Initially, 70 operations performed under original control conditions were included, after which the first behavioural measure was introduced (i.e. better use of the plenum). Cultures were taken during 67 operations using better use of the plenum (Group 1), followed by disciplinary measures and the installation of a new laminar flow system. Seventy operations were monitored after this second intervention (Group 2). The control group showed intra-operative contamination in 32.9% (23/70) of cases, Group 1 showed contamination in 34.3% (23/67) of cases and Group 2 showed contamination in 8.6% (6/70) of cases. Prolonged wound discharge and superficial surgical site infection decreased significantly in Group 2, as did the incidence of deep periprosthetic infection; however, the latter did not reach statistical significance. This study shows that the combination of systemic and behavioural changes in an operating room significantly decreases the incidence of intra-operative bacterial contamination, subsequent prolonged wound discharge and superficial surgical site infection. After 18 months of follow-up, there was also a decrease in deep periprosthetic infection.