Risk factors for failure after cementless femoral revision THA: a consecutive series of 105 cases.

INTRODUCTION: Cementless femoral revision total hip arthroplasty (RTHA) after periprosthetic fracture, aseptic loosening or infection is a challenging surgical procedure. The aim of this study was to evaluate the incidence and reasons for failure after two-stage septic revision, periprosthetic fracture or aseptic loosening that may reveal a rationale for cementless RTHA in two-stage revisions. MATERIALS AND METHODS: A consecutive series of 105 cases using cementless femoral revision prostheses were evaluated retrospectively. Indications for revision were 39 two-stage revisions after infection, 49 aseptic loosenings, and 17 periprosthetic fractures. A Kaplan-Meier analysis was performed using infection with or without removal of the implant as an endpoint. RESULTS: Incidence of infection with or without implant removal was significantly higher in patients treated for periprosthetic fractures compared to two-stage revisions or aseptic loosening (log-rank P < 0.0001). The mean follow-up period was 6.4 (2.0-13.7) years. Using infection with or without implant removal as the endpoint, 12 patients were diagnosed after the index operation resulting in a cumulative risk after 13.7 years of 29.9% (95% CI 0-61.2). CONCLUSION: Cementless revision using a modular tapered device is reliable with respect to reinfection risk in two-stage procedures.

> 10-year outcome of dislocated radial fractures with concomitant intracarpal lesions as proven by MRI and CT.

To clarify the role of concomitant carpal lesions in dislocated distal radius fractures (DRF), 104 consecutive patients with DRF underwent a preoperative morphological examination using CT and MRI. The study was performed between 2004 and 2006 with the aim of recording all types of concomitant carpal lesions as well as their consequences after 1 year. Carpal lesions of different types were found in all treated cases of dislocated DRF. A clinical follow-up 1 year (13.9 ± 6.5 months) after surgical treatment showed no correlation between the carpal lesions and the treatment outcome (previously described by Gologan et al. 2011). A second follow-up study ( > 10 years postoperative, range 11.2 ± 0.9 years) was initiated to find suspected later decompensations of the concomitant carpal lesions. A total of 37 of the original 104 patients could potentially be followed up: 22 patients had passed through both follow-ups and 15 could only be contacted with restrictions. 27 patients had died, 24 patients were excluded due to the presence of dementia or explicit rejection, and 16 patients could no longer be found. Using the Castaing score, the first follow-up after 1 year resulted in an average of 4.95 ± 3.1 points (range 0-12; "good result") and the second follow-up after 10 years in an average of 5.91 ± 2.9 points (range 2-14; "good result"). Again, there were no correlations with the primarily recognized carpal lesions [comparable groups 22 vs 22 (identical patients in both follow-ups); lost to follow-up rate 15.4%]. These results suggest that concomitant carpal lesions are primarily prevalent and detectable in (nearly) all dislocated DRF cases. However, with the usual protection of the wrist and the carpus after surgical treatment of DRF, these lesions often do not decompensate or require treatment, even after 10 years.

Arthrodesis for septic arthritis of the ankle: risk factors and complications.

INTRODUCTION: Septic ankle joint arthrodesis is a good therapeutic option in cases of infection after trauma or orthopedic surgical procedures. Many different procedures have been described, but external fixation seems to be standard. Aim of this study is to identify risk factors for complications in septic ankle joint arthrodesis with the external AO frame fixator. MATERIALS AND METHODS: Patients who received septic ankle joint arthrodesis between January 2008 and December 2012 were included in this study. Patients were evaluated clinically and with radiographs or CT scans. RESULTS: Follow-up of 74 of 79 patients with an external AO frame fixator could be evaluated; follow-up was 411 days (105-991). The mean age at surgery was 57.7 years (19-87). At this time, complications occurred in 41 patients (52 %) with wound healing problems (17 patients, 22 %) and non-union (12 patients, 15 %), and some needed surgical revision. In our collective, men had a significant higher non-union rate (p = 0.031), age or BMI showed no difference. Patients with diabetes and alcohol consumption showed a higher risk for complications (p = 0.049 and p = 0.031, respectively). 62 % of primary arthrodesis showed union, whereas in the case of revision, arthrodesis only 39 % showed union. CONCLUSIONS: Septic ankle joint arthrodesis with the external AO frame fixator is a probable tool to achieve union. This study showed that there is a high complication rate and some risk factors for complications could be identified. A blinded and prospective study is needed to compare intramedullary nailing and external fixation to evaluate the possible advantage of intramedullary devices in septic ankle arthrodesis.

High complication rate after septic orthopaedic implant removal of the lower leg.

INTRODUCTION: The aim of the study was to determine predictive risk factors for revision surgery in patients with septic orthopaedic implant removal of the lower leg. MATERIALS AND METHODS: A total of 196 patients with septic removal of orthopaedic implants after primary trauma of the lower leg between 2008 and 2012 were evaluated. Patients with endoprosthesis infection were excluded from this study. RESULTS: Thirteen patients (22.4 %) had infectious complications with revision surgery. We found 14 patients with soft tissue infections, 10 patients with osteomyelitis, 19 patients with wound-healing problems, 10 patients with pin track infections and two patients with fistulas. High complication rates were associated with severity of the initial trauma, localisation, and the state of union or non-union. Patients with peripheral arterial disease, anaemia and smoking showed a significantly higher risk for revision surgery; whereas patients with diabetes and arterial hypertension did not. A total of 22.6 % had open fractures as an initial trauma. In 76 %, bacteria could be detected. The complication rate was 41.2 % after initial open fractures and 19.6 % after initial closed fractures. A higher grade of soft tissue damage showed no increasing complication rate (p > 0.05). CONCLUSIONS: In this study, complications after septic implant removal of the lower leg were evaluated and risk factors were determined. The awareness of the risks for complications after septic orthopaedic implant removal can lead to a better treatment for patients. Decision-making can be based on scientific results to prevent patients suffering from further severe disease progression.

Correct positioning of pedicle screws with a percutaneous minimal invasive system in spine trauma.

BACKGROUND: When performing minimally invasive spine surgery in trauma patients, a short operation time and a perfect positioning of pedicle screws are demanded. In this study, we show that a Minimally Invasive Pedicle Screw System allows both. METHODS: One hundred and twenty-one patients (131 fractures) with fractures between Th 3 and L 5 were treated. The most common fracture type was A3. We treated 52 females and 69 men with a mean age of 56.7 years. In 72% of the cases, the procedure was performed by two experienced spine surgeons. Postoperatively, all patients were examined using a CT-scan. In 61 patients, an anterior stabilization was additionally performed in 33 patients, vertebroplasty or cyphoplasty was performed. Fifteen patients underwent laminectomy. RESULTS: No patient postoperatively developed any additional neurological compromise. In total, 682 screws were placed. In the postoperative CT-scan, we found 16 screws (2.2%) in suboptimal position, 8 with medial and 8 with lateral deviation. DISCUSSION: With the Minimally Invasive Pedicle Screw System used in this study, spinal fractures can be treated in a short operation time with percutaneous stabilization and a correct positioning of the pedicle screws in almost 98%. In our study, no screw was so much malpositioned that revision surgery would have been necessary. LEVEL OF EVIDENCE: Level III - Case-control study.

[Flaps for soft tissue defect closure in the distal lower leg]. / Lappenplastiken zur Defektdeckung am distalen Unterschenkel.

Soft tissue defects in the distal lower leg region are challenging to treat, especially in trauma cases. To achieve early closure of the defect, pediculated adipofascial or muscle flaps can be used as well as free flaps. The pediculated adipofascial suralis flap has a reliable blood supply and a broad radius so this flap can be used for almost every defect location on the distal lower leg except for defects larger than 10 × 10 cm. The donor site defect does not lead to major problems and is well tolerated. The soleus flap can cover defects in the middle third and proximal distal third of the lower leg with its muscle. The donor site defect is occasionally associated with reduced calf functioning but is tolerated well most of the time. Because of these advantages, the pediculated adipofacial suralis flap and the soleus muscle flap can be used instead a microvascular free flap for the closure of defects in the distal lower leg region.

[Soft tissue healing in infected arthroplasty]. / Weichteilsanierung bei infizierter endoprothetik.

OBJECTIVE: Soft-tissue defect coverage with well vascularized tissue (musculocutaneous or fasciocutaneous) in the arthroplasty setting. Where arthroplasty has been removed due to infection, as a muscle flap to close infected cavities. INDICATIONS: Soft tissue defects, wound-edge necrosis in arthroplasty, and persistent infection in Girdlestone patients. CONTRAINDICATIONS: Moribund patients. SURGICAL TECHNIQUE: Pedicled flap: as far as possible, lift the flap as an island flap to increase coverage. Then suture the flap into the defect (split skin graft where appropriate). Free flap: lift the flap and prepare a vascular pedicle for anastomosis. Suture the flap into the site and create arterial and vascular micro-anastomoses (split skin graft where appropriate). POSTOPERATIVE MANAGEMENT: Position the extremity according to the flap type used. Use 500 ml HES (hydroxyethyl starch) 6% for 5 days. Avoid compression of the pedicle or anastomosis area. Flaps are generally autonomous after 3 weeks. RESULTS: The survival rate for both flap types, free and pedicled, is >90%. The flap survival rate should not be confused with the healing rate for infected arthroplasty.

Vastus lateralis muscle flap for infected hips after resection arthroplasty.

We evaluated the potential of a vastus lateralis muscle flap in controlling infection after resection arthroplasty of the hip. We retrospectively reviewed 119 patients with 120 chronic infections after resection arthroplasty treated with this procedure. The flap was fixed with Mitek anchors in the acetabular cavity. The mean duration of infection after resection before the muscle flap procedure was 6.5 months (2 to 13). The patients had previously undergone a mean of 4.9 operations (2 to 25). In all patients the infected cavity was the origin of the persistent infection. The mean follow-up was for 2.6 years (1.0 to 4.7). No patient had recurrent infection post-operatively and all had an improvement in the pain and better quality of life.

[Revision strategy for periprosthetic infection]. / Revisionsstrategie bei der Protheseninfektion.

Periprosthetic infection remains a major complication in arthroplasty; increasing numbers of primary and revision arthroplasties are being followed by increasing numbers of periprosthetic infections. In cases of possible infection, the surgeon must have a treatment concept that can be individually adjusted. Diagnosis is a challenge and should include a variety of investigations. In early and secondary infections, component retention can be successful. Surgical debridement is the key to success. All late and chronic infections should be treated by explantation of all components because of infection with biofilm-producing microbes. The individual patient's situation and the surgeon's experience should determine whether to choose direct single-stage or two-stage revision. New diagnostic and therapeutic procedures can improve outcomes but cannot replace the need for prophylactic efforts.

Instant stem cell therapy: characterization and concentration of human mesenchymal stem cells in vitro.

In regenerative medicine, there is an approach to avoid expansion of the mesenchymal stem cell (MSC) before implantation. The aim of this study was to compare methods for instant MSC therapy by use of a portable, automatic and closed system centrifuge that allows for the concentration of MSCs. The main outcome measures were the amount of MSCs per millilitre of bone marrow (BM), clusters of differentiation (CD), proliferation and differentiation capacities of the MSC. A volume reduction protocol was compared to the traditional laboratory methods of isolation using a Ficoll gradient and native BM. Fifty millilitres of BM were obtained from haematologically healthy male Caucasians (n=10, age 8 to 49 years). The number of colony forming units-fibroblast (CFU-F)/ml BM was highest in the centrifuge volume reduction protocol, followed by the native BM (not significant), the centrifuge Ficoll (p=0.042) and the manual Ficoll procedure (p=0.001). The MSC of all groups could differentiate into the mesenchymal lineages without significant differences between the groups. The CD pattern was identical for all groups: CD13+; CD 44+; CD73 +; CD90+; CD105+; HLA-A,B,C+; CD14-; CD34-; CD45-; CD271-; HLA-DR-. In a further clinical pilot study (n=5) with 297 ml BM (SD 18.6), the volume reduction protocol concentrated the MSC by a factor of 14: there were 1.08 x 10(2) MSC/ml BM (standard deviation (SD) 1.02 x 10(2)) before concentration, 14.8 x 10(2) MSC/ ml BM (SD 12.4 x 10(2)) after concentration, and on average 296 x 10(2) MSC (SD 248.9 x 10(2), range 86.4-691.5 x 10(2)) were available for MSC therapy. The volume reduction protocol of the closed centrifuge allows for the highest concentration of the MSC, and therefore, is a promising candidate for instant stem cell therapy.

[Current short- and long-term results of lumbar disc replacement : update 2008]. / Lumbale Bandscheibenendoprothetik - Update 2008 : Metaanalyse der Kurz- und Langzeitergebnisse.

Lumbar total disc replacement is an increasingly common way of treating degenerative lumbar disc disease while preserving mobility. The aim of this analysis was to survey evidence-based data to classify the procedure. Based on a MEDLINE inquiry, 38 clinical trials dealing with lumbar total disc replacement were selected and analyzed by the criteria of indication, preoperative procedure, and clinical follow-up. These data represent 3,180 patient-related evaluations with follow-up of 5.9 to 204 months. We also included ten retrospective studies. Patient satisfaction was a mean of 90.73%, and the Oswestry Disability Index and Visual Analog Scale were significantly lower. High rates of revision surgery, explantation surgery, and secondary fusions are linked to wrong preoperative indication. According to evidence criteria, the results show that lumbar total disc replacement is a safe procedure with a high rate of success. There is clear evidence that both imprecise indication and the choice of too-small implants significantly reduce the prospect of surgical success and increase the rates of reintervention.