Biofilm Related Total Knee Arthroplasty Infection: Prevention, Diagnosis and Treatment.

Biofilm related implant infection is undoubtedly a relevant challenge in total knee arthroplasty (TKA) with our comprehension steadily progressing and novel management approaches being developed. The aim of this article was to review the most important advances in approaches to combat infections due to biofilm-forming bacteria in TKA. The main conclusions were the following: 1) Fundamental management techniques for infected TKA include open DAIR (debridement, antibiotics, and implant retention), and one and two-stage revision TKA; 2) Continuous local antibiotic perfusion (CLAP) appears to diminish the risk of periprosthetic joint infection (PJI); 3) Restraint of quorum sensing seems to avert PJI after TKA; 4) A recent in vitro study showed promising results in the prevention and management of PJI after TKA using PMMA [poly(methyl methacrylate)] loaded with up to 100 mg of rifampin.

Ultrasound-guided joint procedures in hemophilia: technique, indications and tips.

INTRODUCTION: The therapeutic approach to pain in hemophilia should be multimodal. Intra-articular injections are a good option when joint lesions do not respond to hematological treatment or rehabilitation and orthopedic surgery is not yet indicated. Performing these procedures under ultrasound guidance has been shown to improve their accuracy and efficacy. AREAS COVERED: This article provides a practical overview of the most frequently employed ultrasound-guided intra-articular procedures on the joints of people with hemophilia. The article describes the key elements for performing the technique on the elbow, knee and ankle as the most affected joints. The particularities of the most frequent indications, arthrocentesis, synoviorthesis and analgesic injections with various products are detailed. EXPERT OPINION: Current hematological treatments have made it possible to incorporate new therapeutic tools for pain relief for people with hemophilia, including ultrasound-guided joint procedures, which offer excellent results.

Primary Total Knee Arthroplasty in Hemophilia and Allied Disorders: Revision Rates and Their Causes.

When patients with hemophilia and allied disorders (von Willebrand disease and other congenital bleeding disorders) do not receive adequate primary hematologic prophylaxis from infancy, their joints will suffer knee joint degeneration; when such joint degeneration becomes very advanced (painful and disabling) despite previous conservative treatment, the only way to alleviate the problem will be to implant a primary total knee arthroplasty (TKA). The literature has shown that twenty years after implantation, 71% of primary TKAs are still functional; on the other hand, 18% have to be revised as a consequence of periprosthetic joint infection (PJI). The main causes of revision total knee arthroplasty are PJI and aseptic loosening (39% each).

Discoid LaterL Meniscus: A Concise Literature Update.

Discoid lateral meniscus (DLM) is the most frequent congenital variant of the lateral meniscus, which is prone to degeneration and tears, and frequently causes knee osteoarthritis. The purpose of this article has been to analyze the publications made during 2023 on DLM. The main conclusions of the analysis were as follows: MRI assessment might be helpful to diagnose DLM and detect the presence of instability: two main factors in the decision to perform surgery. Arthroscopic assessment should be utilized in conjunction with MRI findings for complete DLM diagnosis. Restoring the normal shape, retaining adequate width and thickness, and ensuring the stability of the remnant DLM is essential to sustaining the physiological function of the meniscus and preserving the knee. Partial meniscectomy with or without repair should be the first-line treatment when feasible, given that the clinical and radiological long-run results of total or subtotal meniscectomy are worse.

Locking Attachment Plate for the Surgical Treatment of Periprosthetic and Periimplant Fractures: Long-Term Follow-Up.

Objectives: The surgical management of periprosthetic fractures (PPF) and periimplant fractures (PIF) can be challenging. The locking attachment plate (LAP) was proposed in recent years for the osteosynthesis of such fractures. The aim of this study was to assess the experience of a third-level hospital with LAP for the treatment of PPF and PIF, and analyse the clinical outcomes. Methods: Data were prospectively collected and analysed from all patients whose PPF/PIF was treated surgically with LAP in a third-level hospital from June 2018 to June 2022. All fractures were postoperative low-energy femur fractures. The minimum follow-up period was six months. Results: Thirty-eight patients (31 women) met the eligibility criteria. The mean age was 86.3 years. The median time until surgery was 4 days. A mean of 3.61 screws were used for each LAP. The mean femur plate length was 14 holes, and the mean working length 7.1 holes. The median hospital stay was nine days. The mean follow-up was 19.56 months. At one month, 12 patients tolerated partial weight-bearing. Five patients walked independently indoors. One patient had died and seven patients were readmitted. At six months, six more patients had died. Fifteen patients tolerated full weight-bearing (FWB). Nine patients walked independently indoors, six outdoors. Twenty-five patients reached fracture consolidation without malalignment. Nine patients were readmitted. At 12 months, another patient had died. Seventeen patients tolerated FWB. Eleven patients walked independently indoors, six outdoors. Twenty-five patients achieved fracture consolidation without malalignment. Five patients were readmitted. Fourteen patients crossed the two-year postoperative threshold. All achieved fracture consolidation. Two patients passed the 4-year postoperative milestone. Conclusion: The clinical results of patients whose PPF or PIF was treated with the LAP are promising. This fixation method is a viable option to be considered when planning surgery for such fractures.

Re-revision Total Knee Arthroplasty: Causes, Risk Factors and Results.

The rate of re-revision total knee arthroplasty (TKA) ranges between 4% and 10%, depending on the cause of the procedure. Periprosthetic joint infection (PJI) and periprosthetic fracture are the main causes of re-revision TKA. The likelihood of implant survival of re-revision TKA diminishes with each subsequent revision, with PJI being the main cause of multiple revisions. Acute early aseptic revision TKA (within 90 days of surgery) involves a high risk of re-revision at 2 years and a high risk of subsequent PJI. The use of antibiotic-loaded cement is associated with lower risk of re-revision. Patients younger than 50 years experiencing aseptic revision TKA have a 1 in 3 risk of re-revision. Patients revised for instability or having prior TKA revisions have the highest risk of re-revision at 10 years. Patients younger than 55 years experiencing revision TKA have a 5-year revision-free survival of 80%.

Total Hip Arthroplasty in Hemophilic Patients: are their Results Similar to those of Nonhemophilic Patients?

Total hip arthroplasty (THA) is the mainstay therapy for patients with terminal hemophilic arthropathy of the hip. However, the largest case series published between 2017 and 2023 in the literature on THA in patients with hemophilia have found a higher 1-year infection rate (8.1% versus 3.4%) in hemophilia patients than in the general population, a higher rate of in-hospital bleeding complications (38.7% versus 16.1%), a higher length of stay (6 days versus 3 days) and a higher 30-day readmission rate (22.6% versus 4.1%). Finally, a lower 5-year survival rate has also been observed in hemophilia patients than in the general population (91.9% versus 95.3%). In the last decade there have been dramatically positive improvements in implant designs and hematological treatment, and therefore it does not seem that THA in hemophilia is so far from that in osteoarthritic patients.

Intraosseous Regional Administration of Vancomycin Prophylaxis for Primary and Revision Total Knee Arthroplasty.

The advantages of prophylaxis with intraosseous regional administration (IORA) of vancomycin for periprosthetic joint infection (PJI) in primary and revision total knee arthroplasty (TKA) include the ability to deliver antibiotics directly to the surgical bed and avert systemic delivery; the ability to precisely time and quickly administer vancomycin to achieve the highest concentrations at the beginning and throughout the surgical procedure; and the ability to avert several common and potentially serious adverse effects of intravenous vancomycin. Indications for IORA of vancomycin prophylaxis include the following clinical scenarios: revision TKA; obesity; diabetes; beta-lactam allergy; known colonization with methicillin-resistant Staphylococcus aureus (MRSA); individuals coming from institutions with a high MRSA incidence; previous ligamentous surgical procedure or osteotomy; current or recent smokers; in the primary TKA setting if the individual is considered high-risk as defined by the criteria above; and during reimplantation following 2-stage exchange for PJI.

Knee replacement surgery in a patient with acquired von Willebrand disease: a case study with recommendations for patient management.

Introduction and importance: Acquired von Willebrand disease (AvWD) is a rare underdiagnosed bleeding disorder caused by alterations in the levels of the major blood-clotting protein von Willebrand factor (vWF). The clinical and laboratory parameters of AvWD are similar to congenital vWD, but it is found in individuals with no positive family history with no underlying genetic basis. The disease remains multifactorial and incompletely understood. Proposed mechanisms include the development of autoantibodies to vWF, absorption of high molecular weight vWF multimers that impair normal function, shear stress induced vWF cleavage and increased proteolysis.The aetiology of the disease is variable, the most common being hematoproliferation, lymophoproliferation, myeloproliferation and autoimmune and cardiovascular disorders. Consensus and protocols for AvWD patients that require major surgery are currently lacking. Patients with AvWD can experience thrombotic events during surgery as a result of therapeutic interactions with pro-thrombotic risk factors. Case presentation: Here, the authors report a patient with AvWD requiring a knee prosthesis implantation due to chronic pain, limited range of motion and functional impairment. The patient had a high risk of bleeding during surgery and was at risk of thrombosis due to age and obesity. Clinical discussion: Perioperative care required a collaborative approach and the management of bleeding. The patient was administered vWF concentrate Willfact lacking Factor VIII to prevent haemorrhage and to minimize the risk of thrombosis. Conclusion: The treatment was effective and well-tolerated. The authors use this information to provide recommendations for AvWD patients for whom major surgery is indicated.

Arthroscopic ankle surgery in people with haemophilia.

INTRODUCTION: People with haemophilia (PWH) not administered primary haematological prophylaxis since childhood, that is, those treated haematologically on demand or not treated at all, often experience the degeneration of the ankles, leading to pain and functional impairment. AIM: To analyse the outcomes and complications of arthroscopic ankle surgery performed on PWH. METHODS: For this narrative review of the literature, a search was conducted in PubMed on 2, December 2023, using the keywords "haemophilia", "ankle" and "arthroscopy". Of the 29 articles identified, 15 specifically related to ankle arthroscopy in PWH were selected (inclusion criterion). The remaining articles did not meet this requirement (exclusion criterion) and were therefore eliminated. RESULTS: Arthroscopic procedures (arthroscopic synovectomy, debridement and arthrodesis of the ankle) are increasingly used in the surgical treatment of haemophilic ankle arthropathy. Although arthroscopic ankle surgery offers good outcomes in patients with haemophilia, the procedure is not free of complications, which range from 7.9% for arthroscopic ankle debridement to 13.1% in arthroscopic ankle synovectomy and 17.8% in arthroscopic ankle arthrodesis, respectively. The non-union rate of arthroscopic ankle arthrodesis is 7.1% (2/28). CONCLUSION: Although arthroscopic interventions in the haemophilic ankle (synovectomy, debridement, arthrodesis) offer good functional outcomes, they are associated with a non-negligible rate of complications. Arthroscopic ankle surgery in PWH is major surgery and should be treated as such.

Can Isolated Tibial Component Revision Be an Alternative to Isolated Aseptic Loosening of the Tibial Component in Total Knee Arthroplasty?

This article reviews the information on isolated tibial component revision for isolated aseptic loosening of the tibial component in total knee arthroplasty (TKA). It summarizes the results of recent major studies published in PubMed since the beginning of the search engine until 28 March 2023. Sixty-five articles were found, of which only five were analyzed because they were directly related to the title of this article. At 5-year follow-up isolated tibial revision and both-component (femoral and tibial) revision for aseptic loosening did not differ with regard to failures of the implant, adverse events, and clinical outcomes.

Complications of ankle arthroscopy: frequency, prevention, and treatment.

The complication rate of ankle arthroscopy (AA) ranges from 3.5% to 14%. To avoid such complications, it is essential to have a thorough understanding of the anatomy of the ankle, to perform the procedure very carefully and with appropriate instrumentation, and to use a non-invasive distraction technique. The most frequent complications are neurological (cutaneous nerve injuries), which are usually caused by direct injury during arthroscopic portals or by a distracting pin when using an invasive distraction technique. They usually resolve spontaneously within a few months. The iatrogenic formation of a pseudoaneurysm is a severe but extremely rare complication (an incidence of 0.008%). There are several treatments for pseudoaneurysms: external compression; direct thrombin injection, surgical intervention (resection of the damaged segment of the artery and reconstruction with a reversed long saphenous vein interposition graft), and endovascular embolisation. Other rare complications include wound infections (localised superficial infection), problems at the portal incisions (prolonged portal drainage, residual pain in the portal, portal scar dehiscence, cyst at the portal site), type I complex regional pain syndrome, instrument breakage, painful scars and nodules, and a number of other rarer complications. In conclusion, when performing AA, it is important to remember the potential complications and try to avoid them. When they do occur, it is essential to diagnose and treat them appropriately.

Radiofrequency Ablation for the Management of Pain of Spinal Origin in Orthopedics.

Radiofrequency (RF) is a minimally invasive procedure for interrupting or modifying nociceptive pathways to manage musculoskeletal neuropathic and nociplastic pain. RF has been used to manage cervical and lumbar facet joint syndromes. The benefits of RF are the following: it is safer than surgery; it doesn´t need general anesthesia, by that means diminishing the complications; it causes pain alleviation for a minimum of 3-4 months; it can be repeated if needed; it improves joint function; and it minimizes the necessity for oral pain treatment. RF must not be used in pregnant women; unstable joints, uncontrolled diabetes mellitus; and presence of an implanted defibrillator. Even though complications from RF are rare, possible adverse events are infection, hemorrhage, numbness or dysesthesia, greater pain in the procedure area, and differentiation impact. Even though there is a peril of injuring non-targeted neural tissue and other tissues, this can be lessened by carrying out the procedure with the help of fluoroscopy, ultrasonography or computed tomography. RF seems to be a helpful procedure for relieving chronic pain syndromes; despite this, definite proof of the procedure's effectiveness is still needed. RF is an encouraging procedure for treating chronic spinal pain, especially when other procedures are pointless or not feasible.

In the era of primary prophylaxis in hemophilia, what types of orthopedic surgical interventions have been published in the 2020-2023 period and in which countries?

INTRODUCTION: Primary prophylaxis has significantly reduced the number of orthopedic surgical procedures performed on patients with hemophilia (PWH) worldwide. However, studies on orthopedic surgery in PWH are still being published in the medical literature. AREAS COVERED: The aim of this article is to determine the types of orthopedic surgical interventions in PWH published between 2020 and 2023 and the countries in which they are published. EXPERT OPINION: The following orthopedic surgical procedures are still performed on PWH: total knee, ankle, elbow and hip arthroplasty, ankle fusion, ankle distraction, and the surgical removal of hemophilic pseudotumors. The countries in which articles on orthopedic surgery in hemophilia have been published in the period 2000-2023 include China (14 articles); Republic of Korea and U.S.A. (3 articles each); Germany, Italy, Japan, Poland and Turkey (2 articles each); and 1 article each in the following countries: Austria, Belgium, Chile, France, Ireland, New Zealand, Russia, and The Netherlands. These data suggest that primary prophylaxis should be improved and extended to all patients globally.

Elbow Arthroplasty: A Concise Literature Update.

Total elbow arthroplasty (TEA) is increasingly used, especially in patients with rheumatoid arthritis (RA) and distal humerus fractures (DHFs). This narrative review of the recent literature published in 2022 reached the following conclusions: 1) Age greater than 80 is not a contraindication for TEA. 2) The estimated 10-year survival reported for linked TEAs is 92%, and unlinked TEAs 84%. 3) For DHFs in the elderly, regarding the flexion/extension arc, TEA gives substantially better results than open reduction and internal fixation (ORIF). The reoperation and elbow stiffness rates are substantially lower in TEA than in ORIF. 4) Comparing distal humeral hemiarthroplasty (DHH) vs. TEA in individuals over 65 years with a non-reconstructable DHF favors DHH regarding the range of motion but with a similarly high rate of adverse events in the two surgical techniques. 5) The rate of eradication of periprosthetic joint infection (PJI) is 69-76% with two-stage, 71% with resection arthroplasty, 67% with one-stage, 58% with DAIR, and 40% with elbow arthrodesis.

Upper limb and lower limb radiofrequency treatments in orthopaedics.

Radiofrequency (RF) is a minimally invasive technique for disrupting or altering nociceptive pathways to treat musculoskeletal neuropathic and nociplastic pain. RF has been employed to treat painful shoulder, lateral epicondylitis, knee and hip osteoarthritis, chronic knee pain, Perthes disease, greater trochanteric pain syndrome, plantar fasciitis, and painful stump neuromas; it has also been employed before and after painful total knee arthroplasty and after anterior cruciate ligament reconstruction. The benefits of RF include the following:it is safer than surgery; there is no need for general anaesthesia, thereby reducing adverse effects; it alleviates pain for a minimum of 3-4 months; it can be repeatable if necessary; and it improves joint function and minimizes the need for oral pain medication. RF is contraindicated for pregnant women; unstable joints (hip, knee, and shoulder); uncontrolled diabetes mellitus; presence of an implanted defibrillator; and chronic joint infection (hip, knee, and shoulder). Although adverse events from RF are unusual, potential complications can include infection, bleeding, numbness or dysesthesia, increased pain at the procedural site, deafferentation effect, and Charcot joint neuropathy. Although there is a risk of damaging non-targeted neural tissue and other structures, this can be mitigated by performing the technique under imaging guidance (fluoroscopy, ultrasonography, and computed tomography). RF appears to be a valuable technique for alleviating chronic pain syndromes; however, firm proof of the technique's efficacy is still required. RF is a promising technique for managing chronic musculoskeletal of the limbs pain, particularly when other techniques are futile or not possible.

Chronic pain in haemophilia: assessment and analgesic treatment.

People with haemophilia tend to experience pain from an early age because of venipuncture and hemarthrosis. If pain is not properly managed, it can become chronic and bedevil patients throughout their lives. Therapies are currently available that have been shown to effectively treat the different types of pain and their causes. Patients with haemophilia tend to experience either nociceptive or mixed pain. Identification of the cause of pain by means of imaging techniques, and understanding the characteristics, location and intensity of the pain, are essential for a more targeted therapeutic approach. Current data reveal that the most effective measures are administration of haematological and analgesic medication, intraarticular injections, and physical exercise. However, multimodal strategies such as lifestyle changes, physical modalities, psychological support and orthopaedic surgery can also prove of use. This article will look at the most effective analgesic measures used as a part of conservative clinical treatment. Collaborative studies are needed to better understand the nature of pain in the context of haemophilia.

Orthopedic surgical procedures in people with hemophilia.

People with hemophilia tend to develop joint lesions secondary to the recurrent hemarthroses typical of their condition. These usually include chronic synovitis and arthropathy chiefly affecting their ankles, knees, and elbows. In addition, muscular hematomas, albeit less frequently, may also result in complications such as acute compartment syndrome, pseudotumors, bone cysts and peripheral nerve compression. Joint lesions may require some of the following surgical interventions: arthroscopic synovectomy (in cases of synovitis), arthroscopic joint debridement, radial head resection, opening-wedge tibial osteotomy, arthrodesis, arthrodiastasis (of the ankle), tendon lengthening (hamstrings, Achilles tendon), progressive extension of the knee by placing an external fixator in cases of flexion contracture of the knee, supracondylar femoral extension osteotomy in cases of knee flexion contracture and, eventually, a total joint arthroplasty when the affected joint has been destroyed and the patient experiences severe joint pain. Total knee arthroplasty in hemophilic patients is associated with a high infection risk (7% on average). As regards the complications following muscle hematomas, acute compartment syndrome requires urgent performance of a fasciotomy when hematological treatment is incapable of resolving the problem. Surgical resection of hemophilic pseudotumors is the best solution, with those affecting the pelvis (secondary to iliopsoas hematomas) being particularly difficult to resolve. Peripheral nerve lesions can often be effectively addressed with hematological treatment, although a surgical neurolysis of the ulnar nerve is indicated if nonoperative treatment fails.

Total Wrist Arthrodesis: An Update on Indications, Technique and Outcomes.

Painful end-stage wrist osteoarthritis (OA) unresponsive to conservative treatment is frequently managed with total wrist arthrodesis (TWA), which might render pain alleviation and ameliorate function, pain, and grip strength. Usual indications for TWA include inflammatory arthritis, idiopathic degenerative OA and posttraumatic OA, Kienböck's illness, brachial plexus palsy, cerebral paralysis, infraclavicular brachial plexus blocks and other spastic and contracture base illnesses, scapholunate advanced collapse, scaphoid nonunion advanced collapse, and failure of other surgical techniques such as after failed total wrist arthroplasty, four-corner fusion, proximal row carpectomy and severe ligament injuries (this procedure is carried out when all other treatment alternatives have failed to control the individual's symptoms). TWA is commonly carried out with a dorsal plate fixed from the distal radius to the third metacarpal. However, other surgical procedures have been reported, including intramedullary fixation and new implants that do not cross the third carpometacarpal joint or some procedures without utilizing hardware for example using a vascularized fibular grafting In individuals with rheumatoid arthritis. TWA has been shown to give persistent and painless stability for 20 years or more. The rate of adverse events for TWA ranges from 0.1% to 6.1%, though some authors have published that it can be as high as 27%. The most common adverse events are tendon ruptures, peri-implant fractures of the third metacarpal, the need for hardware removal, and constant pain at the third carpometacarpal joint. In idiopathic degenerative OA, the reoperation rate following TWA has been reported as high as 63%. While TWA can render foreseeable pain alleviation and ameliorate function, orthopedic surgeons should remember that this surgical technique is not without its risks and that the accessibility of many surgical procedures requires orthopedic surgeons to scrupulously contemplate the risks and benefits of each alternative for the individual in front of them.

Musculoskeletal Literacy in Orthopedics: Associated Factors, Effects on Patient-Physician Communication and Intervention Strategies.

Health literacy is defined as the degree to which an individual obtains and processes basic health information and services so as to make appropriate and informed health decisions. Limited health literacy (LHL), as assessed by various validated instruments, remains prevalent amongst older adult patients, non-Caucasian ethnicities, and those of lower socioeconomic backgrounds. Of concern, LHL has been associated with decreased medical knowledge, disuse of preventative medical services, worse chronic disease control and increased use of emergency services. Within orthopedics specifically, LHL has been associated with lower expectations regarding outcomes and ambulation following total hip and knee surgery and fewer questions asked regarding diagnosis and treatment in the outpatient care setting. In some cases, LHL has been independently correlated with worse patient-reported outcome measures (PROMs), though this finding may be due in part to the reading level required of the PROMs. There is growing evidence that active intervention by the orthopedic provider and demonstration of empathy improves patient comprehension of the nature of their musculoskeletal complaints, aids informed decision-making and, ultimately, maximizes patient satisfaction. Recognition of the associated factors for LHL will ensure improved physician-patient communication through the implementation of health literate interventions focused on those most at-risk.