Two-stage total joint replacement for hip or knee septic arthritis: post-traumatic etiology and difficult-to-treat infections predict poor outcomes.

PURPOSE: Septic arthritis (SA) is a rare but significant clinical challenge in orthopedics that can impact patients' quality of life. This study aims to examine the clinical outcomes of patients undergoing two-stage total joint replacement (TJR) in hip and knee SA and analyze potential predictors of treatment failure. METHODS: A retrospective analysis was conducted using data from a prospectively collected institutional arthroplasty registry from January 1st, 2012, to January 1st, 2019. Patients with hip or knee SA who underwent a two-stage TJR and had at least two years of follow-up were included. Demographic characteristics, surgical variables, and outcomes were collected and analyzed from clinical and surgical data. Statistical analysis was performed using IBM SPSS Statistics, with statistical significance at p < 0.05. RESULTS: One hundred and fourteen patients (61 with hip SA, 53 with knee SA) were included in the study. The mean follow-up was 72.8 months. Postoperatively, both clinical and functional outcomes significantly improved, as indicated by the Hip Society Score (HHS) and Knee Society Score (KSS). The overall success rate of the two-stage protocol was 89.5%. Complications that did not require revision occurred in 21% of cases. The most identified pathogen was methicillin-sensitive Staphylococcus aureus (MSSA). Difficult-to-treat (DTT) infections and post-traumatic etiology were identified as predictors of treatment failure in patients undergoing two-stage TJR for hip and knee SA. CONCLUSIONS: Two-stage TJR in hip and knee SA demonstrated favorable clinical outcomes at mid-term follow-up. The procedure significantly improved functional scores and achieved a high success rate, while DTT infections and post-traumatic etiology were associated with a higher risk of treatment failure.

Medial gastrocnemius rotational flap for the reconstruction of extensor mechanism disruption in periprosthetic knee infections: a retrospective series with minimum two year follow-up.

PURPOSE: Extensor mechanism disruption following total knee arthroplasty has a prevalence ranging from 0.3 to 3%. Its management is challenging, especially in case of associated infection of the prosthetic implant. Surgical options are limited due to the septic process, and the use of allograft or synthetic mesh are not recommended. The aim of this study was to report clinical outcomes, complications, survival, and surgical technique of medial gastrocnemius flap for the treatment of extensor mechanism disruptions associated with periprosthetic knee infection. METHODS: This is a retrospective study from a prospectively collected arthroplasty registry from 2012 to 2019. Patients who received the gastrocnemius flap in the setting of a two-stage knee replacement for periprosthetic infection were included. Results of physical examination, Knee Society Score, Oxford Knee Score, and measurement of the range of motion registered pre-operatively were compared to those obtained at last follow-up. Survival was analysed through Kaplan-Meier curve. RESULTS: A total of 15 patients were included, with a mean age of 63.4 years (range 36-77). The reconstruction of the extensor mechanism demonstrated a success rate of 73.3%. The mean extension lag at final follow-up was 7.5° (range, 0-30). The mean Knee Society Score and Oxford Knee Score improved from 29.0 (range, 21-36) and 17.5 (range, 13-22) respectively, to 82.9 (range, 74-89) and 36.0 (range, 33-39). CONCLUSION: Medial gastrocnemius rotational flap is a reliable option for joint and limb salvage in case of periprosthetic knee infection associated with wide soft tissue degeneration and extensor mechanism disruption. The technique and surgical protocol presented in this study are reproducible and guaranteed good clinical outcomes and infection control.

Spacer exchange in persistent periprosthetic joint infection: microbiological evaluation and survivorship analysis.

PURPOSE: The purposes of this study were to determine demographics and characteristics of patients who underwent spacer exchange for persistent infection in the setting of two-stage arthroplasty for periprosthetic joint infection, to describe the microbiology of pathogens involved, to analyze survivorship free from infection in these patients. METHODS: The institutional prospectively collected database was reviewed to enroll patients with minimum 2 years follow-up. Patients who underwent two-stage procedure for septic arthritis were excluded, as were patients who had spacer fracture or dislocation. RESULTS: A total of 34 patients (41 procedures) were included. Mean age was 65.0 ± 12.8 years. Mean follow-up was 53.4 ± 24.8 months. Mean number of previous procedures was 3.6 ± 1.2. A total of 27 (79.4%) patients underwent final reimplantation. The most frequently isolated pathogen in spacer exchange was Staphylococcus epidermidis (10 cases, 28.6%). Polymicrobial cultures were obtained from 9 (25.71%) patients, 10 (28.6%) presented culture-negative infections. A total of 11 (32.4%) resistant pathogens were isolated, and 16 (47.0%) difficult to treat pathogens were detected. Eradication rate was 78.8%. Overall survivorship of implants after final reimplantation was 72.8% at 51.8 months. CONCLUSION: Surgeons should be aware that subjects necessitating spacer exchange often present multiple comorbidities, previous staged revision failures, soft-tissue impairment and difficult to treat infection. In these patients, spacer exchange provides good clinical results and infection eradication, preventing arthrodesis or amputation.

Two-stage revision for periprosthetic joint infection in unicompartmental knee arthroplasty: clinical and radiological results.

INTRODUCTION: Unicompartmental knee arthroplasty (UKA) has an infection rate of 0.1-0.8%. Despite the wide amount of literature about septic total knee arthroplasty management, few data are available for UKA infection treatment. The aim is to present the clinical and radiological outcomes along with complication rates of a series of septic UKA treated with two-stage exchange. METHODS: We retrospectively reviewed 16 patient treated with staged UKA revision for infection between June 2015 and September 2019 in a single bone infection unit. The main demographic and surgical data were recorded. Clinical scores (VAS, KSS, OKS, postoperative ROM), radiological parameters (osseointegration, loosening and radiolucencies) and complications were reported. The mean follow-up was 33.5 ± 6.9 months. RESULTS: Mean age at surgery was 68.5 ± 9.1. All but two were medial UKA. The mean number of previous surgeries was 2.9 ± 1.9. The mean ROM, VAS, KSS and OKS of the entire population improved significantly (p < 0.01). Radiological analysis did not show any migration or implant loosening. Ten constrained condylar and six posterior stabilized prosthesis were finally implanted. One intraoperative pathogen isolation was recorded and managed with suppressive therapy and good final outcome. The implant survivorship free from infection was 100% at the final follow-up. The overall survival rate for any reason of revision was 100% CONCLUSION: According to our results, staged revision represents a reliable ad effective option in delayed and late UKA infections. This technique provides optimal clinical and radiological results with acceptable complication rates. To the best of our knowledge, this represent the widest case series on infected UKA managed with two-stage exchange.

Clinical radiographic outcomes and survivorship of medial pivot design total knee arthroplasty: a systematic review of the literature.

BACKGROUND: Total knee arthroplasty is a reliable procedure able to reduce pain and disability in patients suffering from osteoarthritis. However, a considerable percentage of patients still experiences unsatisfactory results. Medial pivot total knee arthroplasty has been introduced in the clinical practice to overcome problems related with classic design implants and better mimic native knee kinematics. The aim of this study was to analyze survivorship and clinical and radiographic outcomes of medial pivot implants. METHODS: A systematic research was conducted in eight different databases. Thirty-four studies met the inclusion criteria and were included in the analysis. Data on objective and patients-reported outcomes, radiographic alignment, and survivorship were collected and analyzed. Revision rate was expressed as revision per 100 components years. RESULT: A total of 3377 procedures were included. Mean follow-up was 85.7 months (range, 12-182). The revision per 100 components years was 0.19, which corresponds to a revision rate of 1.9% after 10 years. Mean post-operative range of motion was 117.3 ± 0.4°. Mean clinical and functional Knee Society Score were, respectively, 85.9 ± 1.1 and 84.7 ± 3.5 at final follow-up. Post-operative femorotibial alignment was 177.1 ± 0.5°. Alfa and beta angles were 95.7 ± 0.1° and 89.2 ± 0.1°, respectively. Gamma and delta angles were 2.3 ± 0.6° and 86.7 ± 0.4°. CONCLUSION: Medial pivoting implants provided excellent survivorship and low revision rate, as well as good-to-excellent results in term of objective and patient-reported clinical outcomes, and reliable correction of radiographic parameters. More high-quality studies with long-term follow-up are needed to clarify the role of medial pivoting implants.

Predictors of failure of two-stage revision in periprosthetic knee infection: a retrospective cohort study with a minimum two-year follow-up.

PURPOSE: Despite the standardization of two-stage knee revision protocols, a high percentage of failures still occurs. Identifying the predictors of failure is necessary to determine appropriate management and counsel for patients with a periprosthetic knee infection. This study aimed to identify risk factors predicting the failure, to describe implant survival, and to report the mid-term clinical outcomes of patients undergoing two-stage revision for periprosthetic knee infection. METHODS: Data of patients who underwent two-stage knee revision from 2012 to 2016 were analyzed, and 108 patients were included. The mean age was 66.6 ± 9.2 years. The mean follow-up was 52.9 ± 15.6 months. Logistic regression was conducted to identify predictors of treatment failure. Kaplan-Meier curves were generated to assess implant survival. Preoperative functional outcomes were compared to those registered at the final follow-up. RESULTS: Difficult-to-treat infections (OR = 4.2, 95% CI 1.2-14.5, p = 0.025), the number of previous surgeries (OR = 1.8, 95% CI 1.2-2.6, p = 0.005), and the level of tibial bone defect (OR = 2.3, 95% CI 1.1-4.7, p = 0.027) significantly predicted the failure of two-stage knee revision. Survivorship of implants was significantly lower for patients presenting these risk factors (p < 0.05). Mean Knee Society Score improved from 49.0 ± 12.0 to 80.2 ± 13.6 (p < 0.001). Mean Oxford Knee Score improved from 22.2 ± 4.9 to 36.1 ± 6.0 points (p < 0.001). CONCLUSION: Difficult-to-treat pathogens, the number of previous surgeries, and the level of tibial bone defect were independent risk factors of two-stage knee revision failure. Overall, the two-stage protocol provided a good survival rate and functional outcome.

Two-stage arthroplasty for septic arthritis of the hip and knee: A systematic review on infection control and clinical functional outcomes.

INTRODUCTION: Septic arthritis of the native hip and knee joint poses particular challenges to orthopedic surgeons. Patients often suffer from several comorbidities, and it could be challenging to find a balance between infection control and adequate function. Two-stage arthroplasty has been addressed as a reliable solution, however the literature on the topic is composed of case series with small sample size. This systematic review aimed to analyze data on infection control and clinical functional outcomes of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee. METHODS: An electronic search of studies published from January 1st, 2000, to June 1st, 2021, was conducted using eight different databases. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Revies and Meta-analysis two authors reviewed the available literature and reference lists to identify papers eligible for inclusion. RESULTS: A total of 21 studies were included, involving 435 procedures. The mean age was 57.3 ± 6.2 (45.8-71.8) years. The mean follow-up was 53.7 ± 18.6 (12-86.7) months. The mean infection eradication was 93.3 ± 6.4%. Mean Harris Hip Score improved from 32.1 ± 10.6 (11.5-42.9) to 87.5 ± 5.7 (80.6-97.8). Mean Knee Society Score improved from 42.9 ± 7.6 (35.9-58.0) to 86.1 ± 5.4 (80.1-96.0). CONCLUSIONS: Two-stage arthroplasty for hip and knee septic arthritis provided high infection control rate and excellent function. Further high-quality studies should be oriented on providing a validated algorithm for diagnosis and treatment of this condition. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Clinical outcomes and survivorship of two-stage total hip or knee arthroplasty in septic arthritis: a retrospective analysis with a minimum five-year follow-up.

PURPOSE: Septic arthritis of the native joint is challenging for orthopedic surgeons because it may lead to wide bone defects and severe impairment of joint function. This study aimed to analyze clinical functional outcomes, the rate of infection eradication, and survival of implants of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee. METHODS: A retrospective single-centre analysis was conducted of patients treated for septic arthritis of the hip and knee joints through a two-stage surgery between 2012 and 2015. Clinical and radiological records were gathered from the prospectively collected Institutional Arthroplasty Registry. Patients' pre-operative Harris hip scores and Knee Society scores were compared with those obtained at the latest follow-up. Kaplan-Meier curves were generated to assess survival of implants. RESULTS: Forty-seven patients were included. The mean follow-up was 85.2 ± 15.4 months. The Harris hip score improved from 39.4 ± 9.9 to 84.5 ± 10.8 points (p < 0.001). The Knee Society score improved from 40.7 ± 8.4 to 86.0 ± 7.8 points (p < 0.001). Knee Society score-function increased from 25.7 ± 14.2 to 85.4 ± 23.4 points (p < 0.001). The infection eradication rates were 92.0% and 90.9% in patients who underwent hip and knee operation, respectively (p = 0.891). Overall survivorship of implants after the second stage was 93.6%. CONCLUSIONS: Two-stage arthroplasty provides good to excellent clinical outcomes in cases of active septic arthritis of the hip and the knee, high rates of infection control, and implant survival.

Use of porous custom-made cones for meta-diaphyseal bone defects reconstruction in knee revision surgery: a clinical and biomechanical analysis.

INTRODUCTION: Although the practice of metaphyseal reconstruction has obtained successful clinical and radiological results in revision total knee surgery, off-the-shelf devices aren't an effective solution for all patients as they do not cover the full range of clinical possibilities. For this reason, during severe knee revisions, custom-made porous titanium cementless metaphyseal cones are nowadays employed as alternative to traditional surgeries. The aim of this study is to understand the benefits gained by the use of the custom-made cones against the performance of more traditional techniques, such as the use of cemented or cementless stems. Thus, a retrospective study on eleven patients and a biomechanical finite element analysis (FEA) was developed, based upon three clinical cases of the clinical analyzed cohort. MATERIALS AND METHODS: Eleven patients underwent staged total knee arthroplasty revision with the use of 16 custom-made cones to correct severe femoral and tibial meta-diaphyseal bone defects. Clinical scores and range of movement were observed during the follow-up period (mean follow-up 26 ± 9.4 months). Reason for surgery was periprosthetic joint infection (PJI) in eight patients and post-traumatic osteomyelitis in the other three patients. Three patients previously affected by PJI were selected among the eleven patients of the clinical population. For those patients, bone geometries and implants during surgery were replicated in silico and analyzed during different daily activities. For the same patients, as alternative solution for surgery, the use of cemented or cementless stems was also simulated by FEA. Stress patterns in different region of interest and risk of fracture in the bone were calculated and compared. RESULTS: No loosening, component migration, or mismatches between preoperative planning and intraoperative findings were clinically registered. Biomechanical results demonstrated that the use of custom-made cones induces a more homogeneously distributed bone stress than the other two techniques that concentrate the stress in spotted regions. The risk of fracture is comparable between the use of custom-made cones and cemented technique, while press-fit configurations increase the risk of fracture (more than 35%). CONCLUSIONS: Based upon the clinical evidence and the findings after the FEAs, the practice of porous custom-made metaphyseal cones in severe revisions of knee arthroplasties is showing promising biomechanical results. The homogeneous stresses distributions and the lower bone stress gradient could justify a reduction of bone fractures and the risk of implant loosening which could be the explanation to the successful clinical outcomes.

Conservative two-stage revision with primary components of infected total hip arthroplasty: An analysis of survival, clinical and radiographic outcomes.

Few studies provide an analysis of conservative two-stage revision of hip periprosthetic joint infection (PJI) and its impact on final outcome. A conservative revision is defined when soft tissues and bone quality enable the use of primary prosthetic components. Data of patients treated for chronic hip PJI who underwent two-stage revision between 2009 and 2016 and had a minimum of 2 years of follow-up were collected. Oxford Hip Score (OHS), Harris Hip Score (HHS) and radiological and microbiological data were retrieved and analysed. Clinical and functional outcome, survival, mortality, eradication, reinfection and re-revision rates within subgroups of patients with primary components and revision components are reported herein. A total of 148 patients underwent two-stage hip exchange with a mean follow-up of 55.6 ± 23.1 months and a mean age at surgery of 64.3 ± 12.7 years. Forty-four percent of patients underwent conservative revision. The mean HHS significantly improved from 40.6 ± 9.4 points to the final value of 87.8 ± 10.5 points (p = .002), and the mean OHS went from 20.3 ± 3.8 points to 40.3 ± 5. points (p< .001). Patients who were treated with primary components or isolated revision stems in the second stage had a significant reduction in surgical times (p< .001). The mortality rate for all causes of death was 6.8%, the eradication rate was 89.9%, the reinfection rate was 4.7% and the reoperation rate was 7.4% without differences between conservative and non-conservative revisions. Two-stage exchange arthroplasty for total hip arthroplasty (THA) PJI is a good strategy that provides satisfactory results, high eradication rates and no further need for revision. The conservative two-stage revision in patients with adequate bone stock represents a feasible option with good results and survival rates.

Permanent Spacers Are a Reliable Solution for Peri-prosthetic Shoulder Infection: A Systematic Review.

BACKGROUND: Peri-prosthetic shoulder infection (PSI), a highly disabling complication of shoulder arthroplasty, often requires additional surgery and prolonged antibiotic therapy. Of strategies proposed to manage this devastating condition, the use of cement spacers, perhaps even as a definitive treatment, is debated. QUESTIONS/PURPOSES: We sought to systematically review the literature on antibiotic-loaded cement spacers as a viable, perhaps definitive, treatment for PSI, evaluating the eradication rates, mechanical reliability, and functional results related to its use. METHODS: We conducted a systematic review of studies published from January 1, 1980, through September 1, 2019. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Review and Meta-analysis, we searched for studies reporting functional and clinical outcomes in patients with PSI treated with a permanent spacer of the shoulder. Two independent reviewers searched eight databases, as well as reference lists of the retrieved articles. RESULTS: After exclusion criteria were applied, 12 studies were included, involving a total of 143 patients. The mean age was 65.8 years; the mean follow-up was 37.4 months. A total of 133 patients (93%) were free from infection at latest follow-up. The mean post-operative active elevation of the shoulder ranged from 48.6 to 90°, the mean abduction ranged from 51 to 75°, and external rotation ranged from 3.6 to 29°. The mean Constant-Murley score ranged from 20.6 to 42 points (out of 100, from worst to best). CONCLUSION: The use of a permanent cement spacer is a reliable solution to PSI in low-demand, older patients with comorbidities, a population in whom it is desirable to avoid additional surgery. Our review found a high rate of infection eradication and moderate-to-good objective and subjective results. However, the overall level of evidence of included studies was very low, and higher-quality studies are needed to clarify the role of permanent spacers in the treatment of PSI.

Cup-on-cup technique: a reliable management solution for severe acetabular bone loss in revision total hip replacement.

BACKGROUND: The management of acetabular bone loss is a challenging problem in revision total hip arthroplasty (rTHA). The goals of treatment are a stable acetabular fixation, implant stability, and restoration of hip centre of rotation.This study aims to report clinical, radiological outcomes and complications at short-term to mid-term follow-up of the cup-on-cup technique in the management of severe acetabular bone loss in rTHA. METHODS: We retrospectively reviewed the records of patient receiving rTHA performed with double porous tantalum cup technique in a single Joint Replacement Unit from 2014 to 2017. Objective and subjective clinical scores (Harris Hip Score, Oxford Hip Score, and visual analogue scale), radiological parameters (centre of rotation, leg-length discrepancy, heterotopic ossification, osseointegration, loosening and radiolucencies) and complications were recorded. We analysed the implant survival rate and periprosthetic joint infection rate. RESULTS: We included 9 patients (9 hips) with a mean follow-up of 35.3 ± 10.8 months. Functional scores showed a statistically significant improvement at the final follow-up (p < 0.01). All patients rated their surgery as satisfactory. The cup-on-cup construct demonstrated radiological osseointegration with the centre of rotation restoration and leg length discrepancy improvement. In 1 patient, periprosthetic joint infection was diagnosed and treated with suppressive antibiotic therapy. No patients underwent acetabular components revision surgery for any reason. CONCLUSIONS: Cup-on-cup technique is a valid and safe solution for reconstruction of selected Paprosky type IIIA and IIIB bone defects with satisfactory clinical and radiographic results at short-term and mid-term follow-up.

Long-term outcome of prosthetic joint infections treated with two-stage revision.

Long-term evaluation of prosthetic joint infection treated with two-stage revision. Retrospective analysis of 102 periprosthetic infections treated with two-stage revision from 2010 to 2012 in Albenga hospital, Italy. During the second stage, samples for microbiological tests were collected. Failure was defined as a persistence of infection during the second stage or as a relapse during follow-up. 102 cases (55 hip, 47 knee) were analyzed. Patients were evaluated for a median of 44 months. 8/102 (8%) had positive cultures at replacement. These patients were treated with long-term antibiotic treatment and in 3/8 (38%) infection was cured. 9 patients were loss to follow-up or died, 6 patients (6%) had a relapse a median of 16,3 months from replanting. Risk factors significantly related to failures were diabetes and infection due to methicillin-resistant staphylococci. Two stage revision requires continued follow up. Screening for infection at replacement suggests prolonged antibiotic treatment.

Clinical study of outcomes after revision surgery using porous titanium custom-made implants for severe acetabular septic bone defects.

PURPOSE: Acetabular bone loss is a challenging problem in revision total hip arthroplasty (rTHA). Severe bone loss is not uncommon especially in periprosthetic joint infection. Surgical options, including revision shells, rings, and cages-with or without bone allograft-are affected by high complication rates and unsatisfactory clinical results. We report our mid-term results of non-flanged, custom-made acetabular components in staged rTHA. METHODS: We retrospectively reviewed all patients undergoing two-stage revision with acetabular custom-made implants between 2014 and 2016 at a single institution. Harris Hip Scores, Oxford Hip Scores, and Visual Analogue Scales for pain were obtained, and radiographical follow-up was performed. Complications were reported and analysed. RESULTS: We included 19 patients (19 hips) with an average follow-up of 42.3 ± 11.8 months. At the time of re-implantation, significant acetabular bone loss according to Paprosky classification (IIC, IIIA-B, and pelvic discontinuity) was detected in our patients. Clinical outcomes showed statistically significant improvement from pre-operative visit to last follow-up (p < 0.01). All custom-made implants had radiological osseointegration, and we did not find any implant complications, such as loosening or malposition. No mismatch between pre-operative planning and intra-operative findings was observed. To date, we report one septic failure managed with second staged revision, and one re-operation for recurrent THA dislocation. CONCLUSIONS: Custom-made acetabular implants showed excellent clinical and radiographic mid-term outcomes with a low rate of related complications, providing implant stability on residual host bone, restoring hip biomechanics, and allowing biological osseointegration. Further long-term studies are needed to confirm preliminary results.

Acetabular custom-made implants for severe acetabular bone defect in revision total hip arthroplasty: a systematic review of the literature.

PURPOSE: The management of acetabular bone loss is a challenging problem in revision total hip arthroplasty (rTHA). The aim of this systematic review is to summarize and critically analyze indications, complications, clinical and radiological outcomes of custom-made acetabular components in rTHA. METHODS: A systematic review of English literature was performed on Medline. Retrospective or prospective studies with minimum 2 years of follow-up (FU) were included. The PRISMA 2009 flowchart and checklist were considered to edit the review. Rates of intra- or post-operative complications, aseptic loosening (AL), periprosthetic joint infection (PJI), reoperations and re-revisions rates were extrapolated. RESULTS: 18 articles with a level of evidence of IV were included. Six hundred and thirty-four acetabular custom components (627 patients) with a mean FU of 58.6 ± 29.8 months were analyzed. The studies showed good clinical and functional outcomes. Custom-made acetabular components allowed a stable fixation with 94.0 ± 5.0% survival rate. The estimated rate of re-operations and re-revisions were 19.3 ± 17.3% and 5.2 ± 4.7%, respectively. The incidence of PJI was 4.0 ± 3.9%. CONCLUSIONS: The acetabular custom-made implants represent a reliable solution for pelvic discontinuity and particular cases of bone loss classified as Paprosky Type IIIA-B or type III-IV according to American Academy of Orthopaedic Surgeons system where the feature of the defect cannot be handled with standard implants. This strategy allows to fit the implant to the residual host bone, bypassing the bony deficiency and restoring hip biomechanics. Satisfactory clinical and radiological outcomes at mid-term follow-up are reported in literature.

Bone Defect Management with Vascularized Fibular Grafts in the Treatment of Grade III-IV Osteomyelitis.

PURPOSE: This study is a retrospective analysis of our experience in microsurgical bone transfers for complex limb reconstructions. The aim of this study is to evaluate reliability of the vascularized fibula technique: infection recurrence, hypertrophy, time to bone union, complications, and time to healing in severe osteomyelitis (Cierny-Mader III and IV) cases over a 38 to 93 month follow-up. PATIENTS AND METHODS: From March 2010 until December 2015, 18 patients' limbs (6 females and 1 2 males; mean age 48.7 years) were reconstructed with 10 free fibula flaps, 5 pedicled fibula flaps, 3 peroneus brevis osteomuscular flaps. We reconstructed 2 radiuses, 2 ulnae, 4 femurs, 4 tibiae, 1 acetabulum and 3 fibular malleoli. RESULTS: We considered as successful results all cases where patients had successful functional bone reconstruction with no recurrence of infection during the follow up (mean time 63.6 months). We obtained 14 complete functional reconstructions, 2 limb salvages with impaired function, and 2 failures which underwent major amputations. In only one case there was an infection recurrence. CONCLUSIONS: The bone defect reconstruction with vascularized fibula grafts in severe bone infections is an effective option, but requires a well trained multidisciplinary team to manage the high rate of complications. Complications, in our series, were demonstrated to be significantly associated to patients defined as B-hosts according to Cierny-Mader's classification (P < 0.05), and caliber discrepancy between fibula and reconstructed bones such as Tibia and Femur (P < 0.005). Furthermore, stress fractures in the grafted fibulae were prognostic indicators for overall treatment failure (P < 0.05).

Reconstructive surgery for thumb osteomyelitis: a new way of remodelling the vascularized medial femoral condyle flap. A case report.

BACKGROUND: Authors propose a technical innovation for the remodelling of the medial femoral condyle flap (MFCF) for reconstruction of small to medium bone defects performed after the surgical treatment of a thumb osteomyelitis. MATERIALS AND METHODS: A 45 year old male had thumb proximal phalanx osteomyelitis after a crush trauma of the dominant right hand and multiple previous unsuccessful surgical attempts in other hospitals. In our centre he underwent to a two stage surgical treatment of the infection through bone and soft tissue reconstruction with a MFCF shaped in a new three dimensional (3D) approach with multiple osteotomies. RESULTS: Bone union was achieved after 30 days with a stable thumb reconstruction and good soft tissue healing. No vascular complication occurred after surgery. There was no sign of infection recurrence. CONCLUSIONS: MFCF offers a variety of options for its 3 D shaping which make it a good solution in hand surgery reconstructions after surgical excision of small and medium size bony segments.

Primary cementless stems in septic hip revision: Indications and results.

PURPOSE: The aim of our work is to evaluate results obtained from a cohort of patients affected by periprosthetic joint infection and treated with a primary cementless stem in a two-stage technique framework. METHODS: Eighty-four patients were evaluated at a mean follow-up of 37.4 months. The main demographic, surgical, clinical, and radiographic data were recorded. A femoral window for stem removal was performed in 33 patients. RESULTS: Statistically significant improvement was noted for both the Harris Hip score and the Oxford Hip score. Postsurgical complications included thigh pain in three patients, subsidence (>2 mm) in one patient, implant dislocation in two patients, cup revision in one patient, implant revision for septic failure in two patients, and stem revision for varus position in one patient. The stem survivorship rate was 96.3%. There were no significant differences between the groups in which a cortical window was created or not. CONCLUSION: Femoral stem revision with primary cementless stems is a viable option in selected patients undergoing two-stage hip revision surgery. Correct indication is a cornerstone of good outcome. The use of a cortical window does not affect the final outcome or implant survivorship rate.

Single Intravenous Administration of Tranexamic Acid in Anterior Cruciate Ligament Reconstruction to Reduce Postoperative Hemarthrosis and Increase Functional Outcomes in the Early Phase of Postoperative Rehabilitation: A Randomized Controlled Trial.

PURPOSE: To evaluate the effect of tranexamic acid (TXA) in patients undergoing anterior cruciate ligament (ACL) reconstruction in reducing intra-articular effusion and affecting clinical outcomes 3 months after surgery. METHODS: Eighty consecutive patients undergoing ACL reconstruction were prospectively assessed from 2014 to 2016. Patients were randomly allocated to 1 of 2 groups: The test group received an intravenous infusion of 15 mg/kg of TXA, and the control group did not receive TXA. The patellar circumference, range of motion (ROM), Coupens and Yates (CY) value, visual analog scale score for pain assessment, and quadriceps strength (QS) were considered on postoperative day (PD) 1, PD 7, and PD 15 and at 1 month and 3 months after surgery. Blood volume in the intra-articular drainage was recorded on PD 1. Any adverse effect, such as fever onset (>37.5°C), hemarthrosis, or infection, was also considered. RESULTS: We found a statistically significant reduction in drainage blood volume (P < .001) and CY value (P = .0044) on PD 1 in patients in the test group compared with those in the control group. On PD 7, a significant improvement was found for mean CY values (P = .0057), ROM (P = .0031), and QS (P = .015). On PD 15, we noted significant improvements in CY values (P < .001), patellar circumference (P = .0019), QS (P = .0089), and visual analog scale values (P = .0032) in the test group. We noted 13 fever episodes in the control group and 2 fever episodes in the study group (P = .047). No differences for any outcomes or complications were found at 3 months. CONCLUSION: TXA administration reduced hemarthrosis and the amount of suction drainage blood volume, improved ROM and QS, and reduced fever episodes during the first 2 weeks after surgery. TXA use improved early-phase outcomes in the postoperative period after ACL reconstruction. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

The Use of Tantalum Metaphyseal Cones for the Management of Severe Bone Defects in Septic Knee Revision.

BACKGROUND: Femoral and tibial massive bone defects are common findings in septic total knee revision and pose considerable challenges for the orthopedic surgeon. The aim of this study was to report the midterm clinical and radiographic outcomes with the use of tantalum cones for the management of massive bone defects after 2-stage knee revision. METHODS: We retrospectively reviewed the medical records of 60 patients (mean age, 67.9 ± 8.8 years) treated with 94 tantalum cones associated with constrained or semiconstrained knee for massive bone loss (mean follow-up, 43.5 ± 17.4 months). In all cases, the indication was a staged revision for periprosthetic knee infection. Functional scores, radiographic outcomes, and implant survivorship were analyzed. RESULTS: The mean Knee Society Score and Oxford Knee Score improved from 44.1 ± 7.4 and 19.2 ± 4.1 to 85.4 ± 5.6 and 38.4 ± 3.9 (P < .01), respectively. The mean flexion increased from 60.6° ± 15.5° to 96.8° ± 10.9° at the last evaluation (P < .01). The mean improvement in flexion contracture was 6.2 ± 8.0 (P < .01). Two failures (3.3%) due to periprosthetic knee infection recurrence were observed, but no cone-related mechanical failures were reported. The cone-related survival rate was 97.8%. CONCLUSION: Excellent clinical and radiographic midterm outcomes were achieved with a low complication rate. Tantalum cones may be considered a safe and effective option in the management of massive bone defects also in septic knee revision surgery.