Total Hip Arthroplasty in Teenagers: A Systematic Literature Review.

BACKGROUND: Total hip arthroplasty (THA) in teenagers is generally avoided. Nevertheless, recent THA procedures in a very young patient show improved functional outcomes and implant survival, resulting in lower revision rates. This review aims to present an overview of the available literature on THA in teenagers and to provide evidence to inform caregivers. METHODS: In this systematic review, studies required a primary THA method and a teenage patient population. Studies must report at least one of the following outcome measures: functional outcomes, implant survival, and complications. In addition, demographic and surgical data were collected. RESULTS: Sixteen studies were analyzed, including 2040 patients and 2379 hips, with an average 7.7-year follow-up. The mean patient age was 18 years, with an average revision rate of 11.7%. The overall average relative improvement of the 2 most frequently used patient-reported (functional) outcome measures were 84.3 and 92.3% at the latest follow-up. Prosthesis, or liner loosening, was the cause of revision in 50.2% of the cases. Loosening was the most frequent complication (14.8%), together with prosthesis/liner wear (14.8%). Cementless fixation (70.7%), ceramic-on-ceramic articulation (34.7%), and the posterior surgical approach (82.3%) were the most applied techniques. CONCLUSIONS: The functional outcomes after THA in teenagers improved at follow-up. The average revision rate is relatively high, especially in the pre-1995 studies, with post-1995 studies reporting similar revision rates to the adult patient group. Research to further improve implant survival as well as the ease of revisions in teenagers is needed. LEVEL OF EVIDENCE: Level III-systematic review.

Rapid Diagnostics of Joint Infections Using IS-Pro.

Diagnosis of bone and joint infections (BJI) relies on microbiological culture which has a long turnaround time and is challenging for certain bacterial species. Rapid molecular methods may alleviate these obstacles. Here, we investigate the diagnostic performance of IS-pro, a broad-scope molecular technique that can detect and identify most bacteria to the species level. IS-pro additionally informs on the amount of human DNA present in a sample, as a measure of leukocyte levels. This test can be performed in 4 h with standard laboratory equipment. Residual material of 591 synovial fluid samples derived from native and prosthetic joints from patients suspected of joint infections that were sent for routine diagnostics was collected and subjected to the IS-pro test. Bacterial species identification as well as bacterial load and human DNA load outcomes of IS-pro were compared to those of culture. At sample level, percent positive agreement (PPA) between IS-pro and culture was 90.6% (95% CI 85.7- to 94%) and negative percent agreement (NPA) was 87.7% (95% CI 84.1 to 90.6%). At species level PPA was 80% (95% CI 74.3 to 84.7%). IS-pro yielded 83 extra bacterial detections over culture for which we found supporting evidence for true positivity in 40% of the extra detections. Missed detections by IS-pro were mostly related to common skin species in low abundance. Bacterial and human DNA signals measured by IS-pro were comparable to bacterial loads and leukocyte counts reported by routine diagnostics. We conclude that IS-pro showed an excellent performance for fast diagnostics of bacterial BJI.

Bilateral massive osteolysis of uncertain origin after total knee arthroplasty: A case report and review of literature.

INTRODUCTION AND IMPORTANCE: Periprosthetic osteolysis (PPOL) is a common complication after total knee arthroplasty (TKA) and is most commonly caused by wear-induced particles. CASE PRESENTATION: We report an unusual case of massive bilateral PPOL in the posterior flanges of the femur and patellae 4 years after bilateral uncemented TKA without patellar resurfacing in a 71-year old female. Bilateral staged revision surgery including polyethylene exchange and allograft morselized bone impaction was performed to treat the osteolytic lesions. There were no signs of implant malalignment, polyethylene wear or component loosening. CLINICAL DISCUSSION: Several factors are associated with an increased risk on PPOL (e.g. polyethylene sterilization method, patient age, male gender). Surgical intervention in the context of massive PPOL should include replacement of a potential particle generator (most often polyethylene), correction of potential malalignment, treatment of bone defects and assessment of implant anchorage. CONCLUSION: This report highlights the available evidence on clinical presentation, associated risk factors and preferred treatment strategy of massive osteolytic lesions after TKA according to available evidence.

Results and Patient Reported Outcome Measures (PROMs) after One-Stage Revision for Periprosthetic Joint Infection of the Hip: A Single-centre Retrospective Study.

Background: Little is known about functional outcome and quality of life (QoL) after one-stage revision for periprosthetic joint infection (PJI) of the hip. Methods: a cohort of 30 subjects treated with one-stage revision between 2011 and 2015 was identified, and questionnaires on functional outcome and QoL were distributed. Results: 28 subjects were successfully treated (93%). Most subjects were referred from other hospitals. Coagulase-negative Staphylococcus was found in 50% of the cases, and 40% of all cultured bacteria were multidrug-resistant. 25% had subsequent revision surgery, unrelated to PJI. Functional outcome was good and QoL scores were high, comparable to prosthetic joint revision surgery in general. Conclusion: Although the cohort was small and statistical analysis was not performed, this study showed that excellent results can be obtained with one-stage revision for hip PJI. Functional outcome and QoL was comparable to prosthetic joint revision surgery in general.

One-stage revision in two cases of Salmonella prosthetic hip infection.

We describe two cases of prosthetic joint infection (PJI) of the hip due to Salmonella. The first patient presented with an early infection 5 d after being discharged following a total hip replacement and the second patient presented at the emergency ward with a late infection, thirteen years following a total hip replacement. Both cases occurred within one month of each other at our institution and both were successfully treated with a one-stage revision. PJI caused by Salmonella species is very rare: so far only 20 Salmonella PJIs of the hip have been described. Therefore, full consensus on the best treatment approach has not yet been reached. An aggressive two-stage approach is advised because of the virulence of Salmonella, although a limited number of successful one-stage approaches have been described as well. According to the latest guidelines, one-stage revision has comparable success rates and less morbidity compared to two-stage treatment, when selecting the right patients. In our opinion, PJI caused by Salmonella should be treated just as PJI caused by other bacteria, with consideration of the selection criteria as mentioned in several treatment guidelines. As illustrated by these two cases, one-stage revision can be successful in both early and late Salmonella PJI of the hip.

Refractures of the paediatric forearm with the intramedullary nail in situ.

Forearm fractures in children are common. When conservative treatment fails, internal fixation with Elastic Stable Intramedullary Nailing (ESIN) become the first choice in the operative treatment of diaphyseal forearm shaft fractures. Refractures with the intramedullary nail in situ are known to occur but formal guidelines to guide management in such fractures are lacking. We present a well-documented case of a radius midshaft refracture in a 12-year-old boy with the intramedullary nail in situ, managed by closed reduction. Literature is reviewed for this type of complication, the treatment of 30 similar cases is discussed and a treatment strategy is defined. The refracture of the paediatric forearm fracture with the intramedullary nail in situ is a rare, but probably under recognised complication which is observed in approximately 2.3% of the study population. Closed reduction may be considered in these cases.

Prosthetic joint-associated infections treated with DAIR (debridement, antibiotics, irrigation, and retention): analysis of risk factors and local antibiotic carriers in 91 patients.

BACKGROUND AND PURPOSE: For prosthetic joint-associated infection (PJI), a regimen of debridement, antibiotics, irrigation, and retention of the prosthesis (DAIR) is generally accepted for acute infections. Various risk factors associated with treatment success have been described. The use of local antibiotic carriers (beads and sponges) is relatively unknown. We retrospectively analyzed risk factors in a cohort of patients from 3 hospitals, treated with DAIR for PJI. PATIENTS AND METHODS: 91 patients treated with DAIR for hip or knee PJI in 3 Dutch centers between 2004 and 2009 were retrospectively evaluated. The mean follow-up was 3 years. Treatment success was defined as absence of infection after 2 years, with retention of the prosthesis and without the use of suppressive antibiotics. RESULTS: 60 patients (66%) were free of infection at follow-up. Factors associated with treatment failure were: a history of rheumatoid arthritis, late infection (> 2 years after arthroplasty), ESR at presentation above 60 mm/h, and infection caused by coagulase-negative Staphylococcus. Symptom duration of less than 1 week was associated with treatment success. The use of gentamicin sponges was statistically significantly higher in the success group, and the use of beads was higher in the failure group in the univariate analysis, but these differences did not reach significance in the logistic regression analysis. Less surgical procedures were performed in the group treated with sponges than in the group treated with beads. INTERPRETATION: In the presence of rheumatoid arthritis, duration of symptoms of more than 1 week, ESR above 60 mm/h, late infection (> 2 years after arthroplasty), and coagulase-negative Staphylococcus PJI, the chances of successful DAIR treatment decrease, and other treatment methods should be considered.

Arthroereisis of the subtalar joint: an uncommon complication and literature review.

Arthroereisis is an operation to prevent abnormal pronation in the subtalar joint in children and adults with symptomatic flexible flatfeet. In the present report, we describe an uncommon late complication of a former variation of this procedure, namely the case of an adult male who experienced migration of a xenogeneic bone graft that had been implanted 55 years earlier. A thorough review of the existing data was also undertaken to better understand the complications of this procedure.

Pelvic reconstruction with a free vascularized distal femur for revision total hip arthroplasty.

The reconstruction of massive structural acetabular defects after revision arthroplasty presents a unique challenge to the orthopedic surgeon. This report describes such a salvage procedure where an autologous vascularized distal femur was used to reconstruct acetabular bone stock with subsequent implantation of a total femoral endoprosthetic replacement that uses a constrained cup and a hinged total knee system. At 2 years of follow-up, there is a good functional result with full incorporation of the graft.

Small cell osteosarcoma of a toe phalanx: a case report and review of literature.

This report describes the radiological and histological findings of a small cell osteosarcoma of a toe phalanx in a 38 year old man. This man presented with pain, swelling and redness of the left third toe. Medical history revealed an osteomyelitis of this toe eight years prior. Based on clinical findings and medical history the lesion was diagnosed as an osteomyelitis. However, peroperatively the lesion had a malignant aspect. Histological examination revealed a small cell osteosarcoma of the proximal phalanx.Osteosarcoma of the foot and especially of the tubular bones is rare. Moreover small cell osteosarcoma is a rare subtype of osteosarcoma. This case demonstrates that medical history and clinical examination can be misleading. In patients with apparent bone destruction, a malignancy must always be excluded prior to treatment. It emphasises the care that should be taken in the process of formulating a diagnosis.

Occlusion of the common femoral artery by cement after total hip arthroplasty: a case report.

INTRODUCTION: The incidence of vascular injuries after total hip arthroplasty is extremely low. In this report we describe an unusual injury to the common femoral artery. CASE PRESENTATION: A 59-year-old Caucasian woman presented with rest pain, numbness and cramps in the operated limb after hip replacement. Cement leakage under the transverse ligament had caused occlusion of the common femoral artery necessitating vascular reconstruction. She had a good functional recovery at follow-up. CONCLUSION: To the best of our knowledge, this is the first well-documented case reporting this pathomechanism of vascular lesion to the femoral artery. This case report highlights the potential risk of such a limb-threatening complication, and awareness should lead to prevention by meticulous surgical technique (correct technique of pressurization) or to early detection of the lesion.

An impinging remnant meniscus causing early polyethylene failure in total knee arthroplasty: a case report.

The management of patients with an apparently normal functional total knee arthroplasty (TKA) suffering from unexplained persistent pain and swelling is a challenging issue. The usual causes of pain after total knee replacement are well known, but there are a small number of patients in whom its aetiology is obscure. Malfunction due to soft tissue impingement has rarely been reported. A patient with an unusual case of posterior soft tissue impingement secondary to a trapped posterior horn of a remnant medial meniscus after TKA and responsible for severe early polyethylene wear, is reported. The diagnosis was confirmed by arthroscopy. Treatment was performed by arthrotomy. The meniscus remnant was removed followed by total synovectomy and isolated exchange of the polyethylene insert. To our knowledge, this is the first well-documented case reporting this association.

Posterior knee dislocation after total knee arthroplasty in a patient with multiple sclerosis. A case report.

A patient with multiple sclerosis (MS) and severe osteoarthritis of the right knee with valgus deformity developed early in the postoperative period a posterior dislocation of the knee after total knee arthroplasty (TKA), due to severe spasm of her hamstring muscles. At revision surgery the posterior cruciate retaining prosthesis was exchanged for a non-linked constrained knee prosthesis. Technical considerations are described for this rare complication, which remains a serious clinical challenge for the orthopaedic surgeon.