What Are the Functional, Radiographic, and Survivorship Outcomes of a Modified Cup-Cage Technique for Pelvic Discontinuity?

BACKGROUND: Pelvic discontinuity (PD) presents a complex challenge in revision hip arthroplasty. The traditional cup-cage construct, which involves a screw-secured porous metal cup and an overlying antiprotrusio cage, has shown promising mid- to long-term results. However, there is limited information on the outcomes of modifications to the original technique. Our study aims to evaluate a modified technique in which the cup position is determined by the placement of the overlying cage, allowing for adjustments to achieve optimal orientation. QUESTIONS/PURPOSES: Among patients treated for PD with a cup-cage construct in which the cup position was dictated by the position of the cage: (1) What are Harris hip scores achieved at a minimum of 2 years of follow-up? (2) What is the Kaplan-Meier survivorship free from aseptic loosening or component migration? (3) What is the Kaplan-Meier survivorship free from revision for any reason? (4) What surgical complications are associated with the procedure? METHODS: Between October 2013 and January 2022, we performed 805 acetabular revisions. Among these, 33 patients with PD confirmed intraoperatively were considered potentially eligible for a cup-cage construct; no other method of surgical management was used. We performed 64% (21 of 33) of these procedures from October 2013 to January 2018, with 6% (2 of 33) of patients lost to follow-up before the minimum study follow-up of 2 years; these 19 patients were monitored over a period ranging from 70 to 115 months. A further 12 patients underwent this procedure from January 2018 to January 2022, with one lost to follow-up before the minimum study follow-up of 2 years; the other patients met the minimum 2-year follow-up requirement. The remaining 30 patients with data analyzed here (10 men, 20 women) had a mean ± SD age of 61 ± 12 years and a median BMI of 29 kg/m2 (range 20 to 33 kg/m2) at the time of revision surgery. Twenty-one patients underwent revision due to aseptic loosening, and nine due to periprosthetic joint infection (PJI). The causes of PD in our patients were as follows: cup aseptic loosening without significant osteolysis in 20% (6 of 30), where the loose cup caused erosion of the host bone, leading to PD; PJI in 30% (9 of 30); intraoperative iatrogenic PD in 3% (1 of 30); and osteolysis in 47% (14 of 30), which also resulted in aseptic loosening. The median follow-up time was 79 months (range 25 to 115 months). The Harris hip score was used to evaluate clinical outcomes, with preoperative values compared with the most recent follow-up. Radiographs were reviewed by two experienced surgeons at each follow-up visit to assess component loosening (defined as migration > 5 mm or the presence of circumferential radiolucent lines) or clear migration. PD was considered healed if bridging callus or trabecular bone was visible across the site of the discontinuity. Complications were assessed through a comprehensive review of electronic medical records. Kaplan-Meier analysis was used to estimate implant survivorship and radiographic loosening, with aseptic loosening or component migration as the endpoint, as well as survivorship free from any reoperation. RESULTS: The Harris hip score improved from a median of 39 (range 30 to 66) preoperatively to a median of 76 (range 30 to 90) postoperatively (median difference 33 [range 2 to 48]; p < 0.01). Within the limitations of two-dimensional (2D) radiographic imaging, successful bone graft integration and the healing of PD were noted in 83% (25 of 30) of patients. Kaplan-Meier survivorship free from radiographic signs of aseptic loosening or component migration was 100% (95% CI 100% to 100%) at 115 months. When any revision related to the acetabular component was considered the endpoint, survivorship free from acetabular component revision at 115 months after revision surgery was 100% (95% CI 100% to 100%). When the need for any reoperation was considered the endpoint, survivorship free from needing reoperation at 115 months after revision surgery was 85% for all patients (95% CI 73% to 100%). When including only patients with a follow-up time of > 4 years (20 of 30), survivorship free from needing reoperation at 115 months after revision surgery was 90% (95% CI 78% to 100%). Postoperative complications during the follow-up period included one early dislocation on the fifth day after surgery, treated with closed reduction and 6 weeks of abduction bracing. One femoral stem loosening occurred at 56 months postoperatively, although the acetabular component remained securely fixed; this patient declined revision surgery. One patient experienced a dislocation 5 months after surgery but refused treatment and opted for prolonged bed rest. Additionally, one patient underwent a debridement, antibiotics, and implant retention procedure 1 week after the revision surgery and subsequently showed no signs of infection at the latest follow-up, 38 months postoperatively. CONCLUSION: Our study highlights the effectiveness of a modified cup-cage technique in complex hip revisions, showing promising results in terms of construct survivorship and low complication rates. Surgeons could consider delaying screw fixation until after positioning the cage within the porous cup to allow for optimal adjustment and using metal augments for severe bone defects to achieve better alignment. Surgeon experience with the cup-cage technique is crucial for achieving optimal outcomes. Future studies should focus on long-term follow-up visits to assess the durability and effectiveness of these modifications and explore the comparative effectiveness versus other methods, such as custom triflange components and jumbo cups with distraction. LEVEL OF EVIDENCE: Level III, therapeutic study.

Determination of vancomycin and meropenem in serum and synovial fluid of patients with prosthetic joint infections using UPLC-MS/MS.

Numerous studies have suggested that intra-articular administration of antibiotics following primary revision surgery may be one of the methods for treating prosthetic joint infection (PJI). Vancomycin and meropenem are the two most commonly used antibiotics for local application. Determining the concentrations of vancomycin and meropenem in the serum and synovial fluid of patients with PJI plays a significant role in further optimizing local medication schemes and effectively eradicating biofilm infections. This study aimed to establish a rapid, sensitive, and accurate ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for determining the concentrations of vancomycin and meropenem in human serum and synovial fluid. Serum samples were processed using acetonitrile precipitation of proteins and dichloromethane extraction, while synovial fluid samples were diluted before analysis. Chromatographic separation was achieved in 6 min on a Waters Acquity UPLC BEH C18 column, with the mobile phase consisting of 0.1% formic acid in water (solvent A) and acetonitrile (solvent B). Quantification was carried out using a Waters XEVO TQD triple quadrupole mass spectrometer with an electrospray ionization (ESI) source in positive ion mode. The multiple reaction monitoring (MRM) mode was employed to detect the following quantifier ion transitions: 717.95-99.97 (norvancomycin), 725.90-100.04 (vancomycin), 384.16-67.99 (meropenem). The method validation conformed to the guidelines of the FDA and the Chinese Pharmacopoeia. The method demonstrated good linearity within the range of 0.5-50 µg/ml for serum and 0.5-100 µg/ml for synovial fluid. Selectivity, intra-day and inter-day precision and accuracy, extraction recovery, matrix effect, and stability validation results all met the required standards. This method has been successfully applied in the pharmacokinetic/pharmacodynamic (PK/PD) studies of patients with PJI.

Ninety-day postoperative mortality and complications in continuous and unselected single-stage revisions for chronic periprosthetic joint infection.

PURPOSE: Single-stage revision has gained significant attention as a major surgical approach for periprosthetic joint infection (PJI). However, the 90-day mortality and complication profile of single-stage revision is poorly characterized. The purposes of this study were to determine the incidence rates of and identify the risk factors for 90-day postoperative mortality and complications of single-stage revision for chronic PJI. METHODS: A retrospective review was conducted on patients who underwent single-stage revision for PJI between August 2000 and May 2022. Patient demographics, 90-day mortality, and postoperative complications were recorded. Complications were categorized into systemic and local complications. Patients in this study were further categorized into knee and hip revision groups. Univariate and multivariate logistic regression analyses were performed to identify significant independent predictors of the outcome measures. RESULTS: 348 patients (144 knees and 204 hips) were included in this study. The 90-day mortality rate was 0.9%. The incidence rates of postoperative complications in knee and hip surgeries were 31.3% and 19.6%, respectively. The most common complication was deep-vein thrombosis (DVT). Rheumatoid arthritis (RA) was the independent predictor of mortality. In the knee revision group, fungal infection was identified as the independent predictor of recurrent PJI; regular alcohol use was predictive of wound dehiscence. Among hip PJI patients, age ≥ 80 years was independently associated with DVT; RA was found to be a predictor of dislocation and wound dehiscence. CONCLUSION: For continuous and unselected patients with chronic PJI, single-stage revision demonstrated a satisfactory 90-day mortality. Nevertheless, the 90-day postoperative complication rates after single-stage revision in both knee and hip groups were relatively high.

Intraoperative Direct Sonication of Implants and Soft Tissue for the Diagnosis of Periprosthetic Joint Infection.

BACKGROUND: Sonication is very efficacious for the microbiological diagnosis of periprosthetic joint infection (PJI), but it involves many steps and multiple workplaces and personnel and therefore carries a potential contamination risk. We present an innovative version of the sonication culture method that involves direct sonication of the retrieved implant and soft tissue, without a sonication tube, intraoperatively and incubation using a BACT/ALERT 3D blood culture system to enhance the efficacy of microbiological diagnosis of PJI. METHODS: We performed a prospective study of consecutive patients requiring implant removal and classified them as having PJI or aseptic failure according to standard criteria. The removed prosthetic components and adjacent soft tissue were directly sonicated in a small metal container, without a sonication tube, during the operation. The sonication fluid was immediately incubated in blood culture bottles in the operating room and cultured in the BACT/ALERT 3D blood culture system. The synovial fluid was also cultured in the BACT/ALERT 3D system to serve as a comparison. RESULTS: Of the 64 included patients, 36 had PJI and 28 had aseptic failure. Fluid from direct sonication and conventional synovial fluid showed sensitivities of 91.7% and 55.6% (p < 0.001) and specificities of 82.1% and 92.9%, respectively. Fourteen cases of PJI were detected by culture of fluid from direct sonication but not by culture of synovial fluid. Higher sensitivity was obtained by direct sonication of only tissue than by direct sonication of only the implant (88.9% versus 75.0%). No significant difference in detection time was found between Staphylococcus aureus and coagulase-negative Staphylococcus. CONCLUSIONS: When combined with incubation in BACT/ALERT bottles, direct intraoperative sonication of implants and soft tissues without a sonication tube was more sensitive than conventional synovial fluid culture and could reliably and rapidly detect the bacteria commonly found in PJI. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of clinical outcomes between the olecranon osteotomy approach and the Bryan-Morrey approach for total elbow arthroplasty.

BACKGROUND: This study aims to investigate the clinical efficacy of the olecranon osteotomy approach and the Bryan-Morrey approach in total elbow arthroplasty (TEA). METHODS: In this retrospective study, 49 patients with elbow disease were treated with TEA. A total of 22 patients with TEA by olecranon osteotomy approach were designated as group A, and 27 patients with TEA by Bryan-Morrey approach were designated as group B. There were 22 males and 27 females, aged 32-82 years with a mean age of 62 years. There were 44 cases of unilateral elbow joint, including 27 cases on the left elbow and 17 cases on the right elbow, and 5 cases of the bilateral elbow joint. There were 6 cases of osteoarthritis (7 elbows), 18 cases of rheumatoid arthritis (22 elbows), 14 cases of traumatic arthritis (14 elbows), 7 cases of distal humeral fractures (7 elbows), and 4 cases of elbow tuberculosis (4 elbows). For each group, we recorded the operative time, intraoperative bleeding, elbow flexion, extension, pronation, supination, postoperative complication rates, and Mayo Elbow Performance Score after surgery. RESULTS: Operative time and intraoperative bleeding were less in group A than in group B (53-120 min [70 (62.5, 78) min] vs. 64-105 min [77 (73, 87) min], and 10-200 ml [50 (20, 90) ml] vs. 5-250 ml [100 (50, 150) ml], P < .028). The elbow flexion, pronation activity, and Mayo Elbow Performance Score were higher in group A than in group B, [(121 ± 12)° vs. (112 ± 10)°, 85 (85,85)° vs. 80 (77,85)°, and (94 ± 3) points vs. (91 ± 4) points, P < .036], while elbow extension and supination activity and complication rates were not statistically significant in either group. CONCLUSION: Compared to Bryan-Morrey approach, the olecranon osteotomy approach to TEA provides adequate visualization, saves operative time and reduces bleeding, provides better flexion activity, effectively improves elbow function, and achieves satisfactory clinical outcomes.

[Effectiveness of total elbow arthroplasty via olecranon osteotomy approach].

Objective: To investigate the effectiveness of total elbow arthroplasty (TEA) via olecranon osteotomy approach. Methods: Between January 2011 and December 2021, 22 patients (25 sides) with elbow joint disease were treated with TEA via olecranon osteotomy approach. There were 9 males and 13 females with an average age of 52.0 years (range, 32-80 years). The disease involved unilateral elbow joint in 19 cases, including 12 cases on the left side and 7 cases on the right side, and 3 cases with bilateral elbow joints. There were 3 cases (3 sides) of osteoarthritis, 7 cases (9 sides) of rheumatoid arthritis, 6 cases (7 sides) of traumatic arthritis, 4 cases (4 sides) of distal humeral fracture, and 2 cases (2 sides) of elbow tuberculosis. The operation time, intraoperative blood loss, and postoperative complications were recorded. The Mayo Elbow Performance Score (MEPS) and range of motion (ROM) were used to evaluate the elbow joint function, and imaging was used to review the position of the prosthesis and the healing of the osteotomy. Results: The operation time ranged from 53 to 120 minutes (mean, 90.6 minutes); intraoperative blood loss ranged from 10 to 200 mL (mean, 68.4 mL). All incisions healed by first intention. All patients were followed up 3.9-126.7 months, with a median time of 47.6 months. At last follow-up, the MEPS scores of 22 patients ranged from 72 to 100 (mean, 91.6); the elbow joint function was rated as excellent in 17 sides, good in 7 sides, and fair in 1 side, with an excellent and good rate of 96%. Elbow joint ROM was 98°-140° in flexion (mean, 119.7°), 5°-23° in extension (mean, 13.9°), 70°-90° in anterior rotation (mean, 83.3°), and 63°-90° in posterior rotation (mean, 79.4°). The follow-up time of 17 patients (20 sides) without fracture and joint stiffness before operation was 3.9-126.7 months, with a median time of 53.9 months; at last follow-up, the MEPS score and the elbow joint ROM were significantly better than those before operation ( P<0.05). The follow-up time of 5 patients (5 sides) with fracture and joint stiffness before operation was 12.0-124.2 months, with a median time of 40.1 months. At last follow-up, MEPS scores ranged from 89 to 100 (mean, 91.2), and elbow joint ROM restored. Two cases (2 sides) developed ulnar nerve symptoms after operation, and 1 case (1 side) suffered from periprosthetic fracture and periprosthetic infection after revision, and the elbow prosthesis was removed. The prosthesis survival rate was 96%. During follow-up, no prosthesis loosening occurred. Conclusion: The intraoperative visual field exposure of TEA via the olecranon osteotomy approach is sufficient, which can reduce the incidence of complications such as triceps weakness and ulnar nerve injury, effectively improve the function of the elbow joint, and obtain satisfactory effectiveness.

Effective single-stage revision using intra-articular antibiotic infusion after multiple failed surgery for periprosthetic joint infection : a mean seven years' follow-up.

AIMS: Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition. METHODS: A retrospective analysis included 78 PJI patients (29 hips; 49 knees) who had undergone multiple prior surgical interventions. Our cohort was treated with single-stage revision using a supplementary intra-articular antibiotic infusion. Of these 78 patients, 59 had undergone more than two prior failed debridement and implant retentions, 12 patients had a failed arthroplasty resection, three hips had previously undergone failed two-stage revision, and four had a failed one-stage revision before their single-stage revision. Previous failure was defined as infection recurrence requiring surgical intervention. Besides intravenous pathogen-sensitive agents, an intra-articular infusion of vancomycin, imipenem, or voriconazole was performed postoperatively. The antibiotic solution was soaked into the joint for 24 hours for a mean of 16 days (12 to 21), then extracted before next injection. Recurrence of infection and clinical outcomes were evaluated. RESULTS: A total of 68 patients (87.1%) were free of infection at a mean follow-up time of 85 months (24 to 133). The seven-year infection-free survival was 87.6% (95% confidence interval (CI) 79.4 to 95.8). No significant difference in infection-free survival was observed between hip and knee PJIs (91.5% (95% CI 79.9 to 100) vs 84.7% (95% CI 73.1 to 96.3); p = 0.648). The mean postoperative Harris Hip Score was 76.1 points (63.2 to 92.4) and Hospital for Special Surgery score was 78. 2 (63.2 to 92.4) at the most recent assessment. Polymicrobial and fungal infections accounted for 14.1% (11/78) and 9.0% (7/78) of all cases, respectively. CONCLUSION: Single-stage revision with intra-articular antibiotic infusion can provide high antibiotic concentration in synovial fluid, thereby overcoming reduced vascular supply and biofilm formation. This supplementary route of administration may be a viable option in treating PJI after multiple failed prior surgeries for reinfection. Cite this article: Bone Joint J 2022;104-B(7):867-874.

[Comparison of effectiveness of total knee arthroplasty with tantalum monoblock tibial component and cemented tibial plateau prosthesis in patients of different ages].

OBJECTIVE: To investigate the difference of total knee arthroplasty (TKA) with tantalum monoblock tibial component (TMT) and cemented tibial plateau prosthesis in patients of different ages. METHODS: The clinical data of 248 patients (392 knees) who underwent primary TKA between May 2014 and May 2019 and met the selection criteria were retrospectively analyzed. There were 54 males (98 knees) and 194 females (294 knees). Of the 122 patients (183 knees), less than 65 years old, 52 (75 knees, group A1) were treated with TMT and 70 (108 knees, group B1) were treated with cemented tibial plateau prosthesis; of the 126 patients (209 knees), more than 65 years old, 57 (82 knees, group A2) were treated with TMT and 69 (127 knees, group B2) were treated with cemented tibial plateau prosthesis. The baseline data of patients, perioperative indicators [hemoglobin (Hb), hematocrit (Hct), total blood loss, unilateral operation time], effectiveness evaluation indicators [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, visual analogue scale (VAS) score, Knee Society Scoring System (KSS) score, active flexion and extension range of motion (ROM) of the knee joint], complications, and imaging indicators [tibial prosthesis varus angle (ß angle), tibial prosthesis posterior slope angle (δ angle), tibio-femoral angle, occurrence of radiolucent line, prosthesis survival rate] were recorded and compared. RESULTS: There was no significant difference in gender, age, height, weight, body mass index, Kellgren-Lawrence grading, the length of hospital stay, and follow-up time between groups A1, B1 and groups A2, B2 ( P>0.05). The unilateral operation time in groups A1 and A2 was significantly shorter than that in the corresponding groups B1 and B2 ( P<0.05). There was no significant difference in differences of pre- and post-operative Hb and Hct and total blood loss between groups A1, B1 and groups A2, B2 ( P>0.05). There was no significant difference in preoperative effectiveness evaluation indicators between groups A1, B1 and groups A2, B2 ( P>0.05). There were significant differences in the differences of pre- and post-operative WOMAC activity and pain scores, KSS function and pain scores, and VAS scores between groups A1 and B1 ( P<0.05); there was no significant difference in WOMAC stiffness score and ROM ( P>0.05). There was no significant difference in the above indicators between groups A2 and B2 ( P>0.05). There was no significant difference in the incidence of complications (2.7% vs 6.5%, 3.7% vs 3.1%) and prosthesis survival rate (100% vs 97.2%, 100% vs 99.2%) between groups A1, B1 and groups A2, B2 ( P>0.05). During follow-up, there was no significant difference in ß angle, δ angle, and tibio-femoral angle between groups A1, B1 and groups A2, B2 ( P>0.05). In the evaluation of knee X-ray radiolucent line, 2 knees of group A1 and 2 knees of group A2 had radiolucent line at prosthesis-bone interface immediately after operation, and the radiolucent line was gradually filled by new bone, without new radiolucent line. During follow-up, 1 knee of group B1 and 1 knee of group B2 had prosthesis-bone interface radiolucent line, without radiolucent line widening or prosthesis loosening. CONCLUSION: TMT is recommended in patients less than 65 years old, and the two types of prostheses are available for patients nore than 65 years old. However, the long-term effectiveness of the two types of prosthesis in patients of different ages needs further follow-up.

Mid-Term Outcomes of Cementless Total Hip Arthroplasty in Adult Patients with Childhood Hip Infection.

BACKGROUND Patients with hip joint infections in childhood often have many aftereffects of different degrees, regardless of the kind of treatment or natural course. Total hip arthroplasty is currently the most effective treatment for sequelae of childhood hip septic or tuberculous infection. This is a mid-term follow-up study of treatment results of patients who had undergone total hip arthroplasty (THA) with cementless prostheses. MATERIAL AND METHODS We retrospectively analyzed and followed 45 patients (45 hips) who underwent THA with cementless prostheses between 2010 and 2017. There were 45 patients, including 17 men and 28 women. The average age of the patients was 46 years (range, 18-67 years). All hip infections occurred in early childhood or adolescence, and the mean interval between initial infection and THA was 38.2 years (range, 15-60 years). The mean follow-up was 6.1 years (range, 2.7-9.5 years). RESULTS Two patients underwent revision surgery because of loosening of the prosthesis, and 1 patient underwent revision surgery because of a new infection with no relationship with childhood infection during the follow-up. The average Harris hip scores significantly increased from 43.1 to 86.4 (P<0.01), and the average visual analog scale significantly increased from 4.6 to 1.7 (P<0.01). The hip dysfunction and osteoarthritis outcome scores were also significantly changed (P<0.01) at the final follow-up. There were 2 cases of transient sciatic nerve palsy and intraoperative periprosthetic fractures in 3 cases. During follow-up, single revision was performed after 6 years of primary arthroplasty because of aseptic loosening in 2 cases and prosthesis infection in 1 case, which was not related to childhood pathogens. CONCLUSIONS THA for patients with sequelae of hip joint infection has a satisfactory effect that can effectively relieve joint pain and improve hip function. The recurrence rate of infection after either pyogenic infection or tuberculous is very low. The mid-term outcomes of THA in this setting were satisfactory, with high prosthesis survivorship and hip function scores.

The fate of immunocompromised patients in the treatment of chronic periprosthetic joint infection: a single-centre experience.

PURPOSE: Immunocompromised patients with periprosthetic joint infection (PJI) are rare and currently there are no reliable guidelines according to which these infections can be successfully managed. The purpose of this study was to report the clinical course of different strategies for treatment of PJI in frail patients. METHODS: A retrospective analysis between 2004 and 2015 included 29 immunocompromised patients (13 hips and 16 knees) with chronic PJI who underwent one-stage revision or debridement, antibiotics and implant retention (DAIR). Patients were stratified according to the Musculoskeletal Infection Society (MSIS) staging system and the clinical course included recurrence of infection and functional outcomes which were extracted from patients' charts. The average follow-up was 68 months (range, 26-149 months). RESULTS: Sixteen of the 29 patients had recurrent infections. At last follow-up, 13 patients were on chronic suppressive antibiotic therapy, three patients died but not one death was considered to be related to the infection. A recurrent infection was observed in 13 of the 24 medically compromised hosts (MSIS type B). Sixteen of the 24 patients underwent one-stage revision; another eight of them underwent DAIR. The infection recurred in three of the five patients (60%) with the worst host grades (MSIS type C). One-stage revision was performed in one of the five patients and the remaining four patients received DAIR. CONCLUSION: Our results show that we should compromise our expectation and intemperate treatment for such a population. The goals of PJI treatment in these patients should take into account their preferences and may pay more attention to the concept of disease control rather than cure, especially for patients with severe comorbidities (MSIS C). LEVEL OF EVIDENCE: Therapeutic Level IV.

Single-Stage Revision for Chronic Fungal Periprosthetic Joint Infection: An Average of 5 Years of Follow-Up.

BACKGROUND: Periprosthetic infections caused by fungal pathogens are a rare entity, and there exist no definite guidelines according to which these infections can be successfully managed. In these situations, we wondered whether patients could be treated successfully for their fungal infections with single-stage revision. METHODS: A retrospective analysis between January 2004 and October 2014 included 11 patients (4 hips and 7 knees) with chronic fungal periprosthetic joint infection who underwent single-stage revision, including aggressive soft-tissue debridement, thorough removal of infected components and cement, pouring powdered vancomycin into the medullary cavity and direct intra-articular injection of fungus-sensitive antibiotics, and a reasonable combination of antifungal agents and antibacterial medications. Recurrence of infection and clinical outcomes were evaluated. The average follow-up was 5 years (range, 2-10 years). RESULTS: There were 3 failures during the study period; 1 patient died during the perioperative period because of acute heart failure on the eighth postoperative day. Of the 11 patients, 7 patients had satisfactory outcomes and required no additional surgical or medical treatment for recurrence of infection. The mean postoperative Harris hip score and Hospital for Special Surgery knee score was 77 points (67-88 points; P < .05) and 78 points (73-84 points; P < .05), respectively, at the most recent assessment. CONCLUSION: Treatment of chronic fungal periprosthetic joint infection with single-stage revision can be fairly effective for achieving acceptable functional outcomes, which indicated that this may be a feasible alternative strategy in selected patients.

Retention of the well-fixed implant in the single-stage exchange for chronic infected total hip arthroplasty: an average of five years of follow-up.

PURPOSE: Removal of an infected prosthesis was considered the gold standard for eradication of infection. However, removal of well-fixed components can result in structural bone damage and compromised reconstruction. In these situations we questioned whether the infection after the total hip arthroplasty could be treated effectively and retain the well-fixed implant in a single-stage exchange. METHODS: A retrospective analysis which included 31 patients with chronic infected THA who underwent major partial single-stage revision, including routinely exchanged femoral head and liner components, aggressive soft tissue debridement, removal of the femoral stem or acetabular cup and retention of the well-fixed component, thorough exposed component brushing, and adequate surgical soaking. Powdered Vancomycin was poured into the surgical area and the infection control rate and clinical outcomes were evaluated. The failure to treat the infection was defined as a recurrence of infection in the same hip. The average follow-up was five years (2-15 years). RESULT: There were four (12.9 %) failures during the study period at an average of 15 months (9-21 months) after partial single-stage revision. Of the 31 patients, 27 (87.1 %) patients had a satisfactory outcome and required no additional surgical or medical treatment for recurrence of infection. Acetabular cups were revised in 22 patients and femoral stems in nine patients. The mean post-operative Harris hip score at the most recent assessment was 74.6 (68-82). CONCLUSIONS: Treatment of chronic infected THA with retention of the well-fixed implant in a single-stage exchange can be fairly effective in the treatment of infection and achieving acceptable functional outcomes, which indicated that this may be an attractive alternative in highly selected patients. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Midterm Outcome of Cementless Total Hip Arthroplasty in Crowe IV-Hartofilakidis Type III Developmental Dysplasia of the Hip.

BACKGROUND: Developmental dysplasia of the hip (DDH) is widespread in developing countries, and treating Crowe IV-Hartofilakidis Type III DDH in adults requires the use of a highly demanding technique. METHODS: We sought to determine the outcome of cementless total hip arthroplasty using Zweymüller components to treat Crowe IV-Hartofilakidis Type III DDH. Fifty-eight patients (71 hips) with a mean age of 35.8 years at time of index operation were included in our study. The average duration of follow-up was 70.5 months. The acetabular component was placed in the true acetabulum in all cases, and subtrochanteric shortening osteotomy was performed in 61 hips. RESULTS: With any component revision for any reason as the end point, Kaplan-Meier survivorship analysis at 98 months revealed a cumulative survival rate for implanted components of 91.40%. The mean Harris Hip Score improved from 35.6 preoperatively to 82.9 postoperatively. There were 20 cases of intraoperative fracture, 1 case of complete nerve palsy, and 7 cases of transient nerve palsy. Revision surgery was performed in 7 patients because of cup loosening in 1, severe polyethylene wear in 4, cup breakage in 1, and dislocation in 1. CONCLUSIONS: Midterm results for cementless total hip arthroplasty in patients with Crowe IV-Hartofilakidis Type III DDH was satisfactory; however, intraoperative fracture and polyethylene wear were major complications.

[The method and result analyses of pathogenic bacteria culture on chronic periprosthetic joint infection after total knee arthroplasty and total hip arthroplasty].

OBJECTIVE: To analyze the results of pathogenic bacteria culture on chronic periprosthetic joint infection after total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: The medical data of 23 patients with chronic periprosthetic joint infection after TKA or THA from September 2010 to March 2014 were reviewed. Fifteen cases of TKA and 8 cases of THA were included in this study. There were 12 male and 11 female patients with the mean age of 62 years (range from 32 to 79 years), and among them 9 patients with sinus. All patients discontinued antibiotic therapy for a minimum of 2 weeks before arthrocentesis, taking pathogenic bacteria culture and antimicrobial susceptibility test by using synovial fluid taken preoperatively and intraoperatively of revision. Common pathogenic bacteria culture and pathological biopsy were taken on tissues intraoperatively of revision. Culture-negative specimens were prolonged the period of incubation for 2 weeks. RESULTS: The overall culture-positive rate of all 23 patients for 1 week before revision was 30.4% (7/23), and the positive rate of culture-negative samples which prolonged for 2 weeks was 39.1% (9/23). The overall culture-positive rate of patients for 1 week intraoperatively of revision was 60.9% (14/23), and the positive rate of culture-negative samples which prolonged for 2 weeks was 82.6% (19/23). The incubation results of 7 cases (30.4%) preoperatively conformed to that of intraoperation. CONCLUSION: The culture-positive rate of pathogenic bacteria culture can be increased evidently by discontinuing antimicrobial therapy for a minimum of 2 weeks prior to the definite diagnosis.

[Effect of femoral offset change on pain and function after total hip arthroplasty].

OBJECTIVE: To investigate the effects of altering the femoral offset after total hip arthroplasty on postoperative pain and function. METHODS: A total of 162 patients undergoing single total hip arthroplasty between March 2009 and December 2011 met the inclusion criteria. According to difference of femoral offset between operative side and contralateral side, the patients were divided into 3 groups: decreased offset group (< 5 mm, 30 cases), normal offset group (-5-5 mm, 87 cases), and increased offset group (> 5 mm, 45 cases). There was no significant difference in gender, age, and disease duration among 3 groups (P > 0.05). The types of femoral stem and head prosthesis were compared among 3 groups. Short Form 12 Health Survey (SF-12) score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score, and Harris score were used to evaluate the clinical outcomes. RESULTS: Standard offset femoral prosthesis was most used, followed by increased offset femoral prosthesis, and decreased offset femoral prosthesis was least in 3 groups. The types of femoral stem and head prosthesis showed no significant difference among 3 groups (P > 0.05). The patients were followed up 12-33 months (mean, 25 months). There was no significant difference in SF-12 score among 3 groups at 1 year after operation (P > 0.05); there was no significant difference in WOMAC pain and stiffness scores among 3 groups (P > 0.05) except WOMAC body function score (P < 0.05). According to Harris scoring criteria, the results were excellent in 13 cases, good in 8 cases, fair in 7 cases, and poor in 2 cases in decreased offset group; the results were excellent in 42 cases, good in 34 cases, fair in 9 cases, and poor in 2 cases in normal offset group; the results were excellent in 31 cases, good in 12 cases, and fair in 2 cases in increased offset group; and significant difference was found among 3 groups (Z= -3.152, P=0.008). CONCLUSION: Increased offset is more conducive to joint functional recovery and pain relief; decreased offset may lead to joint function deterioration and pain aggravation.

[A meta-analysis for the efficacy and safety of tourniquet in total knee arthroplasty].

OBJECTIVE: To evaluate the efficacy and safety of tourniquet in total knee arthroplasty. METHOD: Studies on comparison between with and without tourniquet in total knee arthroplasty were identified from Medline, PubMed, EMASE, Cochrane Library, CBM, Highwire, CNKI, VIP, Articles Digital Periodicals.All the randomized controlled trials were included for meta-analysis with RevMan 4.2.2 software. RESULTS: Nineteen studies involving 15 in foreign languages, 4 in Chinese were identified. There were 1159 cases of knee replacement patients. The results of meta-analysis indicated that there were statistical difference between two groups on intraoperative blood loss (P = 0.000), the number of deep venous thrombosis (P = 0.020), thigh pain (P = 0.000), knee hematoma (P = 0.030), wound infection (P = 0.040), skin ecchymosis area (P = 0.000), and the increasing rate of knee circumference of 3 days after the operation (P = 0.000), while there were no statistical differences with respect to the total blood loss (P = 0.100), the number of blood transfusions (P = 0.150), operation time (P = 0.120), length of hospital stay (P = 0.350), the number of pulmonary embolism (P = 0.310), and skin blisters (P = 0.170). CONCLUSIONS: The tourniquet for total knee arthroplasty can reduce intraoperative blood loss, but can not reduce total blood loss and the number of blood transfusions transfusion, can not improve operative efficiency, can not shorten the hospitalization time and promote the knee joint functional recovery. Furthermore the tourniquet increases the probability of occurrence on deep vein thrombosis, wound infection, hematoma and ecchymosis knee, it also causes knee swelling and thigh pain. It suggests minimize to use tourniquet in total knee arthroplasty.

[Early clinical outcomes of fixed-bearing versus mobile-bearing total knee arthroplasty].

OBJECTIVE: To compare the early clinical outcomes of primary total knee arthroplasty by a fixed-bearing versus mobile-bearing prosthesis. METHODS: A total of 80 patients with osteoarthritis at our hospital from January 2008 to October 2008 were sequentially and randomly assigned into Group A (fixed-bearing prosthesis) (40 knees) and Group B (mobile-bearing prosthesis) (40 knees). And the data of the range of motion (ROM), Knee Society Score (KSS) and Western Ontario MacMaster (WOMAC) were collected at pre-operation and 6, 12 and 24 months post-operation respectively. RESULTS: The P values were as follows: KSS: 0.754, 0.802, 0.561, 0.764; HSS (Hospital for Special Surgery): 0.737, 0.361, 0.254, 0.330; WOMAC (Western Ontario and McMaster Universities) osteoarthritis index: 0.976, 0.557, 0.946, 0.818; ROM follow-up: 0.519, 0.646, 0.175, 0.276. No significant differences were found in clinical outcomes between two groups. CONCLUSION: The fixed-bearing and mobile-bearing prostheses show no difference in clinical outcomes.