Do Cultures Obtained During Primary THA Predict the Likelihood of Revision?

BACKGROUND: There can be unexpectedly positive culture results during elective hip arthroplasty, but the degree to which these are associated with an increased risk of subsequent premature revision is not known. QUESTION/PURPOSE: Are unexpectedly positive culture results obtained during elective THA associated with an increased likelihood of revision within 5 years of the procedure? METHODS: Between March 2007 and March 2011, the hip unit at our institution performed elective primary THA in 829 patients. We systematically collected three samples in 52% (428 of 829) of the interventions. Of those, 26 patients were excluded because of sampling errors; 94% (402 of 428) had samples that were collected systematically and were eligible for the study. We only considered one hip randomly in bilateral procedures (4% [15 of 428]); patients presenting with acute (< 3 months) periprosthetic joint infection undergoing open debridement (4% [16 of 402]) and patients who died before 5 years of follow-up (2% [seven of 402]) were excluded from the study, leaving 91% (364 of 402) eligible for analysis in this retrospective study of a previous prospective trial. No patient included in the final analysis was lost to follow-up within 5 years from the index surgery. The patient group consisted of 52% (188 of 364) women, with a mean ± SD age of 64.8 ± 13.9 years. RESULTS: Positives culture results were associated with a higher risk of revision within 5 years of the index surgery. The proportion of revision surgery was higher in the group with positive culture results than in those with negative results (10% [eight of 77] versus 2% [seven of 290]; p = 0.01). The difference was mainly attributable to a higher proportion of aseptic loosening in those with positive culture results than in those with negative results (8% [six of 74] versus 1% [four of 290]; p = 0.01). After a multivariable analysis, the only independent variable associated with 5-year revision surgery was the presence of positive results during THA (odds ratio 4.9 [95% confidence interval 1.72 to 13.99]). CONCLUSION: Our findings suggest that bacterial contamination during THA is associated with an increased likelihood of early revision. This higher risk of revision is mainly because of presumed aseptic loosening; thus, efforts should focus on the need to rule out infection. These results not only open new questions that should be answered in new prospective and well-designed studies, but also may help to better select patients to obtain a more favorable outcome after THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Prevalence and Impact of Positive Intraoperative Cultures in Partial Hip or Knee Revision.

BACKGROUND: Our aim is to investigate the impact of unexpected positive cultures on the outcome of partial prosthetic revisions. METHODS: Data regarding patients who underwent a partial hip or knee revision from 2003 and 2012 with the preoperative diagnosis of aseptic loosening was retrospectively reviewed. The protocol of revision included at least 3 intraoperative cultures. Failure was defined as the need for re-revision due to aseptic or septic loosening at 5 years. RESULTS: A total of 99 hip and 46 knee partial revisions were included. All cases had at least 5 years of follow-up. Ninety-seven cases (66.9%) had all cultures negative, 35 (24.1%) a single positive culture and 13 (9.0%) ≥2 positive cultures for the same microorganism. The median time from primary arthroplasty to partial revision was significantly shorter for patients with ≥2 positive cultures (26 months) than in those with all cultures negative (48 months) or with a single positive culture (51 months). Partial revisions performed within the first 5 years of implantation had a higher 5-year re-revision rate. The presence of a single positive culture during the partial exchange was not associated with a higher re-revision rate (2 of 35, 5.7%) than in those with negative cultures (3 of 97, 3.1%). On the contrary, re-revision rate was significantly higher in cases with ≥2 positive cultures (3 of 13, 23.1%) than in those with negative cultures (P = .02). CONCLUSION: Partial revisions performed within the first 5 years from implantation and ≥2 intraoperative positive cultures were associated with a higher re-revision risk at 5 years.

Early clinical and radiological outcomes for the Taperloc Complete Microplasty stem.

The use of short stem designs in total hip arthroplasty is not a new concept, but its popularity has increased as a bone-sparing alternative to traditional stems. This study analyzed the midterm clinical and radiological results of the Taperloc Complete Microplasty stem (Zimmer Biomet® Warsaw, IN, USA). A total of 32 patients (20 men and 12 women) were retrospectively documented and received 40 stems (eight bilateral). The median patient age was 50 years (interquartile range 43-58) at the time of surgery. The median follow-up was 36.5 months (interquartile range 26.75-50.25). Indication for total hip arthroplasty was osteoarthritis (62.5% of patients), avascular necrosis (25%), and developmental dysplasia of the hip (12.5%). The Merle d'Aubigné score improved from a mean 11.5 preoperatively to a mean 17.5 at the latest follow-up. During X-ray assessment, we observed one subsidence of the stem (3 mm) and four cases of varus malalignment without clinical consequences. No cases of osteolysis were reported, and no stems were revised. According to our results, this short tapered stem shows a good early-term outcome. Prospective results and a longer follow-up are needed to assess the long-term survival of this stem fully.

Preliminary Results After Changing From Two-Stage to One-Stage Revision Arthroplasty Protocol Using Cementless Arthroplasty for Chronic Infected Hip Replacements.

BACKGROUND: The objective of our study is to evaluate our preliminary results after changing from a 2-stage revision arthroplasty protocol to a 1-stage revision arthroplasty protocol using cementless arthroplasty for all patients with chronic infected hip replacements. METHODS: Prospective study of all hip arthroplasties that were diagnosed with chronic infection and were treated using the 1-stage revision without taking into account the traditional criteria used to determine the use of a 1-stage revision was conducted. There were 2 main variables evaluated: infection control and costs. The definitive diagnosis of infection of the revision was determined using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated using average cost in USD, excluding social expenses, as described by Klouche (2010) for 1-stage or 2-stage revisions. RESULTS: Nineteen patients were included in the study and the infection was controlled in 18 patients. The total economic savings for our hospital for these 19 patients was 391.609 USD. CONCLUSION: This clinical success has led to an important change in our hospital in treating chronic infected hip replacements and an important cost reduction from an economic point of view.

Hypertrophy of the tensor fascia lata muscle as a complication of total hip arthroplasty.

INTRODUCTION: Hypertrophy of the tensor fascia lata muscle (HTFLM) is a rare complication after total hip arthroplasty (THA) and is a potential source of pain, palpable mass, or both. MATERIALS AND METHODS: We retrospectively analyzed 1285 primary THAs and 482 THA revisions (THAR) performed at our center from 2008 to 2014. Among these, five patients had HTFLM (average age 68.8 years). The type of surgery and symptoms were evaluated, as were imaging studies (CT or MRI) of both hips (10 hips), and functional outcomes with the Merle d'Aubigné score. RESULTS: The suspected diagnosis was established at an average of 30.2 months after surgery. Four cases occurred after THA and one case after THAR. A modified Hardinge approach was used in four cases and a Röttinger approach in one case. Two cases had pain and palpable mass in the trochanteric region and three cases only pain. The asymmetric HTFLM of the THA side against the nonsurgical side was confirmed by measuring the cross section of the tensor fascia lata muscle on imaging. The sartorius muscle was measured for reference in each case. The Merle d'Aubigne scale had a mean value of 16.6 (range 13-18) at 38 months after the procedure. CONCLUSIONS: HTFLM after THA is a benign condition that could be mistaken for a tumor when presenting as a palpable mass. We propose that it should be considered in the differential diagnosis of pain in the lateral aspect of hips that have previously undergone THA.

Is hip resection arthroplasty a successful definitive treatment?

Purpose: Hip resection arthroplasty as a definitive treatment is an uncommon indication, although still in use selectively. This study evaluates a cohort of patients who have undergone hip resection arthroplasty surgery indicated as a definitive treatment, in order to assess the rate of re-operation, the rate of infection, and the mortality rates. Methods: We conducted a retrospective, observational, descriptive analysis of a cohort of patients who had undergone a hip resection arthroplasty intended as a definitive treatment, in two University Hospitals from 1994 to 2020. The exclusion criteria were the implantation of a hip cement spacer, or a temporary hip resection arthroplasty in patients undergoing a two-staged surgical approach. We found 26 cases of hip resection arthroplasty. We recorded the indications for a definitive hip resection arthroplasty, the outcomes and complications, and analyzed the success of the hip resection arthroplasty as a definitive surgery using a Kaplan-Meier curve. Results: Seven cases (26.9%) required a re-operation after the hip resection arthroplasty, four cases for persistent hip infection, and in the three remaining a conversion to a total hip arthroplasty was re-considered due to a good medical evolution and non-tolerance to the low functional outcome. The mortality rate was 61.5% (27 days-20 years), with a 19.2% mortality rate in the first 5 years. All the cases that required another surgery after the hip resection arthroplasty were re-operated within the first 18 months. Conclusion: Unfortunately, hip resection arthroplasty continues to show elevated re-operation rate and early mortality rate, as well as low functional outcomes. Two-staged hip revision arthroplasty is the surgical treatment of choice in patients suffering from a periprosthetic joint infection, however we believe that hip resection arthroplasty should be considered in fragile patients, who have endured multiple revision surgeries, or their comorbidities make them unfit from further surgeries.

Usefulness of serum D-dimer and platelet count to mean platelet volume ratio to rule out chronic periprosthetic joint infection.

Background: Diagnosing periprosthetic joint infection (PJI) is challenging and usually requires the evaluation of several biomarkers. Our main aim was to evaluate the usefulness of D-dimer levels as well as the platelet count (PC) to mean platelet volume (MPV) ratio serum as biomarkers to rule out chronic knee and hip infection. Methods: The study enrolled a prospective cohort of 93 patients undergoing hip or knee revision. D-dimer values, PC to MPV ratio, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were preoperatively determined and evaluated as a predictor of PJI. The definitive diagnosis of PJI was established according to the 2018 International Consensus Meeting criteria. Results: A total of 24 (25.8 %) cases were postoperatively diagnosed with PJI. The median D-dimer value was significantly higher ( p   <  0.001) for patients with PJI (1950 ng mL - 1 ) than for patients with aseptic failure (700 ng mL - 1 ). The area under the receiver operating characteristic curves for D-dimer, CRP and ESR was 0.820, 0.793 and 0.791 respectively. D-dimer  ≥  950 ng mL - 1 (91 % sensitivity, 64 % specificity), CRP  ≥  1.95 mg dL - 1 (61 % sensitivity, 90 % specificity) and ESR  >  20 (74 % sensitivity, 82 % specificity) were identified as the values with the best balance between sensitivity and specificity. The mean PC to MPV ratio was 37.0 for PJI patients and 29.8 for patients in the aseptic revision cohort ( p = 0 .067). Conclusions: Serum D-dimer levels appear very unlikely to remain normal in the presence of chronic PJI. The 91 % sensitivity when considering 950 ng mL - 1 as the threshold highlights D-dimer as the most accurate initial test to rule out chronic PJI. Conversely, the PC to MPV ratio may be of limited value for accurately diagnosing PJI.

Removal of protruding screws in a painful total hip arthroplasty: A case report.

Persistent pain after total hip arthroplasty can be challenging for the orthopedic surgeon. We present a case of a 56-year-old female with an uncommon cause of persistent pain after total hip replacement, due to protruding screws with the subsequent impingement of surrounding soft tissues. The patient presented persistent groin pain after total hip revision surgery. After ruling out infection and loosening, an infiltration of iliopsoas muscle was performed, with only temporary improvement. The magnetic resonance depicted the conflict of the screws with the surrounding soft tissues, in close relation to the iliopsoas muscle, the external obturator muscle and the sciatic nerve. Revision surgery was performed, removing the screws, and implanting a new liner with complete remission of symptoms. Our case presents an atypical cause of pain due to surrounding tissue lesions by offending screws with complete resolution after only screw removal. In the clinical study of persistent pain following a total hip replacement, screws length, and protrusion should be considered and ruled out as a possible and treatable etiology. Removal of the screws after cup integration can be a conservative and effective strategy to treat the pain.

The Spaso technique: a prospective study of 34 dislocations.

BACKGROUND: The Spaso technique has been recently described as a new, simple, and effective manoeuvre for reducing anterior shoulder dislocation. However, there is a lack of series in the English literature. The aim of the study was to evaluate the results obtained with the introduction of this technique in an emergency department. METHODS: An observational prospective study at the Hospital Clínic of Barcelona Orthopaedic Emergency Department was done from January 2007 to May 2007. In this period, the Spaso technique was applied in 36 anterior shoulder dislocations. Two of the patients were excluded due to a presentation later than 24 hours after the dislocation, leaving a total of 34 dislocations in 33 patients. They occurred in 22 male and 12 female shoulders. The patients' ages ranged from 21 to 80 years (average, 51 years). The success of the attempt, complications, and other data were collected. RESULTS: The Spaso technique was successful in 23 (67.6%) of the 34 anterior shoulder dislocations. If just those patients with previous shoulder dislocations were taken into account, the success rate increased to 83%. No complications were observed. CONCLUSION: Based on the results of the present study, we consider the Spaso technique as a safe and effective manoeuvre for the reduction of anterior shoulder dislocations, with an acceptable success rate similar to the classical techniques previously described.

Internal fixation of proximal humerus fractures using the T2-proximal humeral nail.

INTRODUCTION: Surgical management of proximal humerus fractures remains controversial and there is an increasing interest in intramedullary nailing. Created to improve previous designs, the T2-proximal humeral nail (PHN) (Stryker) has been recently released, and the English literature lacks a series evaluating its results. We present a clinical prospective study evaluating this implant for proximal humeral fractures. METHOD: We evaluated the functional and radiological results and possible complications. Twenty-nine patients with displaced fractures of the proximal humerus were treated with this nail. One patient was lost right after surgery and excluded from the assessment. Eighteen patients were older than 70 years. RESULTS: There were 21 fractures of the proximal part of the humerus and 7 fractures that also involved the shaft; 15 of the fractures were two-part fractures (surgical neck), 5 were three-part fractures, and 1 was a four-part fracture. All fractures healed in a mean period of 2.7 months. There was one delayed union that healed in 4 months. One case of avascular necrosis of the humeral head was observed (a four-part fracture), but remained asymptomatic and did not require further treatment. In one case a back-out of one proximal screw was observed. A final evaluation with a minimum 1 year follow-up was performed by an independent observer; in 18 patients, the mean Constant score was 65.7 or 76.1% with the adjustment of age and gender; in 19 patients, the mean Oxford Shoulder Score was 21.7. The results obtained with the T2-PHN nail indicate that it represents a safe and reliable method in the treatment of two- and three-part fractures of the proximal humerus. The proximal fixation mechanism diminishes the rate of back-out of the screws, a frequent complication described in the literature. Better functional results were obtained from the patients younger than 70 years, but these were not statistically significant.

Pasteurella multocida septic shock after a cat scratch in an elderly otherwise healthy woman: a case report.

Pasteurella multocida, a gram-negative coccobacillus, is a commensal in the nasopharynx of many animals. P. multocida infections most commonly involve the skin, soft tissues, and respiratory tract, particularly in immunosuppressed patients. The present case illustrates a severe articular infection caused by this bacterium, leading to septic shock, in an elderly, otherwise healthy woman, after a simple scratch of a cat.

Relationship between femoral offset and dislocation in preformed antibiotic-loaded cement spacers (Spacer-G®).

INTRODUCTION: A reduction in femoral offset may decrease muscle tension and lead to spacer dislocations even though proximal femur, musculature and acetabulum remain intact. In this study, we aimed to determine whether postoperative lateral femoral offset (LFO) and modified vertical femoral offset (MVFO) values affect the risk of dislocation of a hip spacer. MATERIALS AND METHODS: We measured LFO and MVFO in properly centred, postoperative, anteroposterior radiographs of the pelvis in 66 patients (71 spacers). We then compared the operated and non-operated sides and recorded any dislocations. RESULTS: Although LFO decreased (p<0.001), the reduction was not associated with dislocation (p = 0.471). MVFO remained unchanged after spacer implantation (p = 0.277) and was not associated with dislocation (p = 0.418). CONCLUSIONS: In conclusion, the preformed spacer decreased LFO but not MVFO compared with the contralateral hip. The variations did not significantly affect the dislocation rate.

Trabecular TitaniumTM cups and augments in revision total hip arthroplasty: clinical results, radiology and survival outcomes.

BACKGROUND: Large acetabular defects remain a challenge in hip revision arthroplasty. Experience with Trabecular Titanium™ (TT) cups (Limacorporate S.p.a.) has not been widely reported. Therefore, we assessed the survivorship and clinical and radiological outcomes of patients receiving TT cups, with or without supplementary trabecular titanium hemispherical modules for acetabular reconstruction, in primary and revision total hip arthroplasty (THA). METHODS: Between January 2009 and July 2014, we performed 67 revisions and 5 primary THAs using TT cups in 69 patients. To achieve stability and/or restore the hip's centre of rotation, hemispherical modules were used in 17 cases based on preoperative templating and/or intraoperative findings. Mean follow-up was 30.5 months. Acetabular bone defects were classified according to the Paprosky classification. Survivorship, functional outcomes (Merle d'Aubigné) and radiological outcomes were analysed. RESULTS: 8 patients underwent cup revision: 2 for loosening, 3 for infection, and 3 for hip dislocation. The remaining cases did not present radiological signs of loosening. None of the cases with Paprosky type I classifications needed revision, while 4 with type II and 4 with type III needed revision (p = 0.028). The respective mean values for pain, walking, and range of motion (Merle d'Aubigné scores ± standard deviation) were 3.6 ± 1.4, 3.7 ± 0.7, and 3.8 ± 0.6 preoperatively, and 5.7 ± 0.7, 5.3 ± 0.7, and 5.6 ± 0.7 at the latest follow-up (p<0.001). CONCLUSIONS: In the short term, results with TT cups appear to be encouraging, with satisfactory survival rates for both simple and complex cases.

La irrupción de la Medicina 2.0 en la educación médica / The emergence of Medicine 2.0 in medical education

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Plate osteosynthesis for severe olecranon fractures.

PURPOSE: To review outcomes of 10 patients who underwent plate osteosynthesis for severe olecranon fractures. METHODS: Records of 7 men and 3 women aged 33 to 73 years who underwent plate osteosynthesis for severe olecranon fractures were reviewed. All had some degree of soft-tissue injury; 6 presented with associated fractures. Seven patients were treated with a limited contact dynamic compression plate, and the remaining 3 received a locking compression plate. Patients were followed up for fracture healing, range of motion, nerve damage, heterotopic ossification, infection, hardware complaints, and the need of a secondary surgical procedure. The Mayo Elbow Performance Score (MEPS) was determined at the final follow-up. The patient-answered questionnaire (PAQ) portion of the Liverpool Elbow Score (LES) was evaluated 2 to 37 months later by telephone. RESULTS: All patients had bone union. None had nerve damage or heterotopic ossification. Patients 4, 6, and 8 with type-IIIB fractures developed deep infections and severe soft-tissue swelling; all had been treated with the limited contact dynamic compression plate. Four patients underwent plate removal owing to hardware complaints. One patient underwent a secondary procedure to restore complete range of elbow motion. The mean MEPS score was 84 (range, 35-100); 5 patients attained excellent scores, one good, 2 satisfactory, and 2 unsatisfactory. The mean PAQ portion of the LES score was 31 (range, 23-36). CONCLUSION: Plate osteosynthesis achieves satisfactory results for severe olecranon fractures. The deep infection rate is higher in patients with severe soft-tissue injury.

Alignment guided by computer navigation of the femoral component in hip resurfacing.

Surgical navigation systems are offered to provide more precise implantation of the femoral component in hip resurfacing (HR), allowing to reduce the risk of malpositioning and of femoral neck fracture and notching. We conducted a retrospective analysis of 30 HR divided into two cohorts and compared the results of a nonnavigated group (15 hips) with those of a navigated group (15 hips). The BrainLAB Computer Navigation System was used in all cases. No notching occurred in either group. The femoral component did not show better positioning in the navigated group, but more outlier cases were observed in the nonnavigated group (7, versus 3 in the navigated group). Although there are no long-term studies showing that surgical navigation increases the survival of HR, the avoidance of outlier values justifies its use, especially during the surgical learning curve, which is a difficult and lengthy one.

Cortical strut allograft as an adjunct to plate fixation for periprosthetic fractures of the femur.

The use of cortical strut allografts in the treatment of periprosthetic femoral fractures remain controversial. Complications such as infection and the potential transmission of disease remain concerns. A retrospective review at a tertiary-care hospital was completed of 21 patients who had sustained a periprosthetic femoral fracture and who were treated using a plate and a deep-frozen cortical strut allograft, between 1996 and 2007. The average age at the time of surgery was 80.3 years old and included 16 women and 5 men. Three patients were lost to follow-up and four died within a few weeks of discharge. The remaining 14 patients were evaluated clinically and radiographically with a mean follow-up of 3.2 years. Fracture union was observed in 13 patients, and integration of the graft occurred in 12 patients. One of the 14 patients developed a deep infection with Coagulase-Negative Staphylococcus, with a satisfactory outcome after surgical debridement and antibiotic treatment. There were no cases of fixation failure or plate rupture. At the final evaluation, the mean EQ-5D VAS score was 64 (ranging from 40-90 points) and the mean EQ-5D health state index adapted to Spanish value sets was 0.57. The mean Oxford Hip Score was 31.2. The results support the use of cortical allograft for these fractures to increase the likelihood of fracture healing and to improve the bone stock. We consider that cortical strut grafting is specially indicated for B1 and C fractures in which decreased bone density is present.