Cemented vs cementless stems for revision arthroplasties due to Vancouver B2 periprosthetic hip fracture.

PURPOSE: According to Vancouver classification, B2 type fractures are most often treated with removal of the loose stem and implantation of a long stem that bypasses the fracture site. However, there is a controversy about the stem fixation that should be used: cemented or cementless. Hence, this study aims to compare cemented and cementless stems in prosthetic revision due to Vancouver B2 (VB2) periprosthetic hip fracture. METHODS: A retrospective study was done including all the patients treated with stem exchange due to VB2 periprosthetic hip fracture in a tertiary hospital between 2015 and 2022. Patients were divided into two groups according to the stem fixation used: cemented or cementless. Functional outcomes, hospital stay, surgical time, complication rate, and mortality were compared between the two groups of patients. RESULTS: Of the 30 included patients, 13 (43.4%) were treated with cementless stems and 17 (56.7%) with cemented stems. There were no statistically significant differences in age, gender, anesthesia risk scale (ASA) or functional capacity prior to the intervention. Patients treated with cementless stems had a higher complication and reintervention rate than those treated with cemented stems: 62 and 45% versus 34 and 6% (p = 0.035; p = 0.010), respectively. Furthermore, in the group of cementless stems a higher proportion of non-union was found (53.8% vs. 17.6%; p = 0.037). Also, the hospital stay (33 vs. 24 days; p = 0.037) and the time to full weight-bearing (21 days vs. 9 days; p < 0.001) were longer in the cementless stem group. CONCLUSION: Cemented fixation in stem revision due to Vancouver B2 periprosthetic hip fracture could be an optimal option with faster recovery which could decrease the rate of complications and reintervention, without compromising the fracture healing and patient mortality. Thus, this option can be considered when an anatomical reduction can be obtained, especially in elderly patients with multiple comorbidities in which a less aggressive surgical option should be considered.

Fused hip conversion to total hip arthroplasty with the direct anterior approach: surgical technique on a regular surgical table under fluoroscopic guidance.

PURPOSE: Conversion of a fused hip to a total hip arthroplasty (THA) is technically challenging due to the loss of anatomical references. Here, a reproducible technique using the direct anterior approach (DAA) with a regular surgical table under fluoroscopic guidance is described, which has several advantages over traditional such as lateral or posterior approaches. METHODS: There were reported 11 cases of ankylosis hip that were converted to THA using the same surgical technique protocol. Clinical and radiographic outcomes were recorded at 3.2 years of follow-up. A detailed preoperative evaluation was performed, including a pelvis radiological evaluation and magnetic resonance image (MRI) to assess the integrity of the periarticular soft tissue and flexor muscles. RESULTS: The DAA has considerable advantages, such as allowing more precise targeting during surgery, avoiding the risk of pseudoarthrosis due to the absence of a trochanteric osteotomy, preserving the abductors, and allowing an easier-to-use of intraoperative fluoroscopy due to the supine position. Besides, the use of a standard table reduces surgical time and allows assessment of limb length, hip stability, and impingement in all planes in an intraoperative dynamic range, which decreases postoperative complications. CONCLUSION: Conversion from hip fusion to THA is a rare and complex procedure. The use of DAA with a standard table and fluoroscopy helps to avoid high complications since it allows a dynamic intra-operative examination of the range of motion to rule out impingements, reduces the risk of dislocation, and allows leg lengthening verification.

Vancouver B2 periprosthetic hip fractures treatment: fix or replace? A retrospective study comparing both techniques.

INTRODUCTION: Vancouver B2 periprosthetic hip fractures involve stem stability and they have been classically treated with revision surgery. Crucial factors such as age, clinical comorbidities and functional status are often neglected. The current study aims to compare clinical outcomes between patients treated with open reduction and internal fixation (ORIF) or femoral stem exchange. METHODS: This is a retrospective study that includes all Vancouver B2 periprosthetic hip fractures in a tertiary referral hospital from 2016 to 2020. Patients were divided into two groups: Group 1. Patients treated with an ORIF and Group 2. Patients treated with stem replacement. The outcomes that were compared between groups included demographic data, functional capacity, complications and mortality. RESULTS: 29 periprosthetic Vancouver B2 fractures were finally analyzed. 11 (37.9%) were treated with ORIF (Group 1) and 18 (62.1%) by stem replacement (Group 2). Surgery time (143 vs. 160 min), hemoglobin drop (1.8 vs. 2.5 g/dL) and hospital stance (25.5 vs. 29.6 days) were shorter in Group 1. According to complications, 18.2% of patients in the ORIF group had orthopedic complications compared with 44.4% in the revision group. In the revision group, 3 cases needed a two-stage revision and one of these revisions ended up with a resection arthroplasty (Girdlestone). The first-year mortality rate was 27% in Group 1 and 11% in Group 2. DISCUSSION: ORIF treatment seems to be a less aggressive and complex procedure which can lead to a faster general recovery. Revision surgery can imply a higher risk of orthopedic complications which can be severe and may require further aggressive solutions. The ORIF group mortality was similar to the proximal femur fracture rate (20-30%). In conclusion, ORIF treatment seems to be a good option especially in fragile patients with low functional demand when anatomical reduction is possible.

Simultaneous ipsilateral knee dislocation and hip fracture: A case report.

Hip fracture is one of the main causes of medical attendance in trauma centers. By contrast, knee dislocation is a challenging and limb-threatening injury. We report a case of a 68-year-old male who sustained a simultaneous ipsilateral hip fracture and knee dislocation after a low-energy fall. Popliteal artery and common peroneal nerve injuries were associated. Knee dislocation treatment included closed reduction, external fixation and popliteal artery repair. Hip hemiarthroplasty was performed using a direct anterior approach. Revision multiligament knee reconstruction surgery was not considered. A rehabilitation program achieved a good long-term functional outcome. Simultaneous ipsilateral knee dislocation and associated proximal femoral injuries are rare and challenging, potentially requiring long-term staged management. The direct anterior approach to the hip is worth consideration when additional lower limb injuries are present, especially in the setting of a knee spanning external fixator.

Iliopsoas impingement after total hip arthroplasty: Does the CT-scan have any role? Our Algorithm proposal.

Introduction: The first surgical option considered in managing iliopsoas impingement following THA is endoscopic/arthroscopic iliopsoas tenotomy, because of its low risk and minimal invasiveness. Acetabular revision is a much more aggressive surgery, recommended only in cases of substantial cup malposition. However, there are no clear indications for this procedure. The purpose of this article is to analyse the role of CT-scan measurement of acetabular cup positioning in a therapeutic algorithm for iliopsoas impingement. Methods: In this retrospective observational study, we reviewed 25 patients treated for iliopsoas impingement following THA between 2011 and 2019. We studied acetabular cup positioning using CT-scan. We compared radiological parameters of patients who presented with significant clinical improvement with conservative treatment and with tenotomy against those who did not. Finally, we developed a proposed therapeutic algorithm. Results: Forty-eight percent of patients presented a significant clinical improvement following conservative treatment. Patients who did not improve were found to have greater acetabular cup axial and sagittal overhang (p-values 0.016 and 0.003). These patients were considered for tenotomy. Of this group, those who did not improve with surgery (38%) showed greater axial overhang (p-value 0.005). Conclusions: Conservative management should be the first line of treatment. In cases of non-operative treatment failure, axial acetabular cup overhang measured by CT-scan can be a useful tool in choosing between iliopsoas tenotomy or cup-revision surgery in selected cases of very severe acetabular malposition. A cut-off point of 10 mm of axial overhang is a reliable predictor of higher failure risk with iliopsoas tenotomy.

Is routine blood typing and screening necessary before primary total hip or knee arthroplasty in the 21st century?

BACKGROUND: Blood loss warranting transfusion is a relatively rare complication of major-joint arthroplasty procedures like total knee arthroplasty (TKA) and total hip arthroplasty (THA). Despite this rarity, pre-transfusion testing (blood typing, screening, and cross-matching) has become routine. We sought to determine if such routine testing is necessary for patients who undergo a primary TKA or THA by (1) measuring the current rate of intraoperative transfusions in primary TKA and THA patients, (2) identifying risk factors for transfusions, and (3) calculating the costs of such blood typing and screening. STUDY METHODS: We retrospectively examined the records of 992 patients who underwent primary TKA, THA, or unicompartmental knee arthroplasty (UKA) to identify patients requiring intra-operative or in-hospital postoperative transfusions. Demographic and baseline clinical and laboratory data also were collected and analyzed to identify predictors of transfusion. Cost analysis was performed. RESULTS: The rate of intraoperative transfusion was 1.7% (17/992 patients), with rates of 2.1%, 1.6%, and 0% for TKA, THA, and UKA respectively. The in-hospital transfusion rate was 10.3%, with corresponding postoperative transfusion rates of 9.1%, 12.9%, and 2%. The only baseline variable significantly linked to transfusions on multivariable analysis was preoperative hemoglobin level, with preoperative Hgb <12 g/dl predictive of transfusions in both TKA (p = .02) and THA (p = .024) patients. DISCUSSION: Our study suggests that pre-transfusion testing for all patients undergoing primary UKA, TKA or THA is unnecessary. We recommend reserving routine pre-transfusion testing for patients with preoperative hemoglobin levels below 12 g/dl.

Should we employ preoperative templating in hip hemiarthroplasty after femoral neck fracture? A nested case-control study.

INTRODUCTION: Dislocation following hip hemiarthroplasty is a serious complication. It remains unclear if acetabular morphology is associated with a higher risk of dislocation. The aim of our study was to investigate whether there are differences in hip morphology radiological parameters between patients who have suffered a dislocation episode, and those who have not suffered a dislocation. MATERIAL AND METHODS: Between January 2015 and December 2018, a nested case-control study was performed. From 707 patients who underwent hip hemiarthroplasty because of femoral neck fracture, 50 patients (50 hips) suffered an episode of dislocation. They were randomly matched with 94 patients (100 hips) without dislocation (ratio 1:2). Clinical data regarding demographics, medical comorbidities and surgical and radiological parameters were studied. RESULTS: Statistically significantly smaller lateral centre-edge angle (LCEA) and femoral offset (FO) and greater Tönnis angle were found in the dislocation group. No differences in acetabular angle were seen. Neurological impairment prevalence was statistically significantly higher in patients who suffered a dislocation (60% vs. 44%, p = 0.011). CONCLUSIONS: The current study suggests that a smaller LCEA and FO, a greater TA, and neurological impairment could be related to a higher risk of hip hemiarthroplasty dislocation after femoral neck fracture in the elderly. We consider that preoperative templating could be helpful in identifying abnormal parameters and carefully planning surgery could lead to changes in treatment strategy, such as choosing a dual-mobility total hip arthroplasty.

A comparative of a single novice surgeon's direct anterior approach and posterior approach learning curves in total hip arthroplasty: a retrospective cohort study.

INTRODUCTION: The purpose of the present study was to compare a novice surgeon's learning curves with the direct anterior approach and posterior approach in total hip arthroplasty. METHODS: A consecutive series of 376 total hip arthroplasties performed from November 2014 to September 2019 in a level-one healthcare center by a single surgeon (V.B) were retrospectively studied. Demographic data, functional outcomes, and complications were collected and compared. RESULTS: Within the ranks of the patients studied, we found differences between groups with respect to dislocation rate and length of stay; these were lower in the direct anterior approach (DAA) group. The approach was not associated with an increase in complications, but rather with a decrease in the rate of dislocations and better functional outcomes at 1-year follow-up. Operative time was initially higher with this approach, but equalized during the learning curve. CONCLUSION: The DAA can be safe even in the early stages of a novice surgeon's learning curve. It does not present a higher complication rate than the posterior approach, either in infection rate or in periprosthetic fractures. However, the DAA may provide greater functionality, lower dislocation rate and a shorter hospital stay. It can also be concluded that after having performed a certain number of interventions, operative time for the DAA can be comparable to that of other approaches.

Direct anterior approach provides better functional outcomes when compared to direct lateral approach in hip hemiarthroplasty following femoral neck fracture.

PURPOSE: This study aims to compare the differences between direct anterior approach (DAA) and direct lateral approach (DLA) in hip hemiarthroplasty (HHA) after displaced femoral neck fracture (FNF) in early functional outcome, hospital length of stay, morbidity and mortality rates. METHODS: This non-interventional retrospective study, carried out at a tertiary trauma centre within the Spanish National Health System, included all patients who underwent a bipolar HHA between 1st January 2018 and 31st December 2019 performed by 2 of our hip unit surgeons. RESULTS: A total of 94 patients were included (40 in DAA group and 54 in DLA group). Median follow-up was 19.2 months (range 8-30.8 months). Postoperative degree of mobilisation showed statistically significant differences in favour of DAA group, where 35% of patients were able to walk with no assistance after surgery. DAA group had 1 day less of hospitalisation in contrast with DLA group overall (8 days vs 9 days, respectively, p < 0.05). Statistically significant differences were not detected in comparing postoperative complications, re-operations rates or 6-months mortality rate. CONCLUSION: Our study highlights the benefits of DAA for HHA after displaced FNF in terms of postoperative mobilisation degree and hospitalisation length of stay when compared to DLA.

Can we trust combined anteversion and Lewinnek safe zone to avoid hip prosthesis dislocation?

INTRODUCTION: Dislocation is one of the most common complications after primary total hip arthroplasty (THA). Combined anteversion (CA) is currently considered one of the most important measures of stability for THA. Thus, the aim of this study is to determine the association between a correct CA after THA and hip prosthesis dislocation, and to analyze the reliability of the Lewinnek safe zone parameters. MATERIAL AND METHODS: This is a non-interventional retrospective study, carried out at a tertiary hospital in Spain. 2489 primary THA in 2147 patients between January 2008 and December 2014 were identified. Clinical, biological and radiographic data, including cup inclination and cup and femoral anteversion, were analyzed of all patients who developed a hip prosthesis dislocation. RESULTS: Thirty-four patients met the eligibility criteria to be analyzed. In 73.5% (25/34) of cases, acetabular anteversion (AV) was correct, with a mean AV of 15.1° ± 9.4°. Femoral anteversion (FA) was considered correct only in 38.2% (13/34) of the dislocated THA, with a mean FA of 8.4° ± 17.2°. Sixteen of these 34 patients (47.0%) presented a correct CA, with a mean CA of 24.2° ± 21.0°. Nineteen hips (55.8%) were within the Lewinnek safe zone. Moreover, eleven patients (32.3%) developed a dislocation even though components were within the Lewinnek safe zone and presented a correct CA. CONCLUSION: Our findings suggest that even when the THA components are positioned within a correct CA and in the Lewinnek safe zone, hip prosthesis dislocations can occur in a not inconsiderable percentage of the cases. Thus, further radiological and clinical analysis should be done to identify potential reasons for hip prosthesis dislocation.

Restoring hip biomechanics during the learning curve of a novice surgeon: Direct anterior approach vs posterior approach.

INTRODUCTION: It remains controversial whether the direct anterior approach (DAA) or the posterior approach (PA) allows better restoration of hip biomechanics after total hip arthroplasty (THA). Besides, it is not certain which approach is best for a novice surgeon to avoid implant malposition, neither during the learning curve nor once the curve plateau has been reached. METHODS: We performed a retrospective cohort study of THAs operated on between 2014 and 2019 by a single novice surgeon (DAA, n = 187; PA, n = 184). The surgeon used both approaches, and thus went through parallel learning curves. RESULTS: While the DAA presented a greater number of acetabular cup implantations within Lewinnek's "safe zone" for inclination (84.5% vs. 79.3%; p = 0.003), the PA returned superior results for anteversion (77.7% vs. 68.4%; p = 0.000). The PA showed a tendency to verticalize acetabular cups, while the DAA tended to antevert them. The DAA resulted in fewer patients with leg length discrepancy (3.2% vs. 8.2%, p = 0.041). No differences were found in stem coronal alignment or femoral offset. CONCLUSION: Both approaches are safe and reliable for restoring hip biomechanics through THA surgery during the learning curve of a novice hip surgeon. Similar radiological outcomes are also seen once the surgeon has reached the learning curve plateau.

Simultaneous bilateral dual mobility total hip arthroplasty dislocation in a patient with hepatic encephalopathy: A case report.

INTRODUCTION AND IMPORTANCE: Dislocation is a severe complication after total hip arthroplasty (THA). It is one of the most common reasons for failure and revision surgery. This is the first case of a documented simultaneous bilateral dual mobility (DM) THA dislocation. CASE PRESENTATION: A forty-nine-year-old man presented with bilateral hip pain, immobility and deformity. X-ray images demonstrated simultaneous bilateral posterior THA dislocation. Previously, the patient had presented atraumatic dislocations recurrently. When he was thoroughly re-interrogated, he complained of uncontrolled and generalized muscle contractions, which were compatible with myoclonus due to hepatic encephalopathy (HE). Multidisciplinary treatment was performed satisfactorily to control myoclonus symptomatology and to prevent dislocation. CLINICAL DISCUSSION: Patient's most important risk factor was a neuromuscular disorder, which we initially gave little notice and undervalued. HE is a serious but reversible syndrome, observed in patients with liver dysfunction. It leads to a wide spectrum of neuropsychiatric abnormalities. Management is based on prevention of episodes, avoiding the underlying triggers. Due to the high risk for dislocation of our patient, we decided to use DM cups bilaterally. This system has demonstrated lower rates of dislocation. CONCLUSION: This case report reminds us that a careful evaluation through meticulous history and physical examination are mandatory when faced with recurrent instability. Furthermore, prevention of dislocation is vastly preferable to treating this challenging complication. High-risk patients should be identified, and appropriate surgical approach, technique and implants have to be collectively used to reach a strategy that mitigates and ideally prevents dislocation.

Core Decompression Combined with Implantation of Autologous Bone Marrow Concentrate with Tricalcium Phosphate Does Not Prevent Radiographic Progression in Early Stage Osteonecrosis of the Hip.

BACKGROUD: Untreated osteonecrosis of the femoral head ultimately leads to secondary coxarthrosis. The aim of this study was to determinate if the core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate could be used to prevent radiographic progression of early stage osteonecrosis of the hip. We also sought to determine whether this treatment improved clinical outcomes and reduced the need for total hip arthroplasty. METHODS: Eighteen hips were included in the present study. All of them underwent core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate between 2007 and 2012. The cell concentrate was obtained from the posterior iliac crest and processed and implanted during the same surgical procedure. Patient demographic data, clinical data including modified Harris hip score, and radiological data were collected preoperatively, postoperatively, and during the follow-up period. Also, survival endpoints were analyzed: time of femoral head collapse and need for total hip arthroplasty. RESULTS: The mean age of patients was 37.8 years (standard deviation [SD], 9.31 years). The mean follow-up was 68.9 months (SD, 15.0 months). In most cases (70.6%), the etiology of the osteonecrosis of the femoral head was corticosteroid use; in the remaining cases, secondary to alcohol use. Core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate did not prevent progression to collapse (< 80% at 5 years) although modified Harris hip scores improved. Overall median survival with the total hip arthroplasty as endpoint was 23 months (95% confidence interval [CI], 14.9 to 31.1 months). Overall median survival time with any degree of collapse as endpoint was 7 months (95% CI, 2.0 to 12.0 months). CONCLUSIONS: The results obtained in this study suggest that core decompression combined with implantation of autologous bone marrow concentrate and tricalcium phosphate will not prevent radiographic progression of early stage osteonecrosis of the hip. These finding also suggest that the absence of indications for hip replacement alone is not an indicator of good response to the treatment, and it is important to note the radiological results.

Effect of Allogeneic Cell-Based Tissue-Engineered Treatments in a Sheep Osteonecrosis Model.

Osteonecrosis of the femoral head (ONFH) is defined as a tissue disorder and successive subchondral bone collapse resulting from an ischemic process, which may progress to hip osteoarthritis. Cell therapy with multipotent bone marrow mesenchymal stromal cells (BM-MSC) of autologous origin appears to be safe and has shown regenerative potential in previous preclinical and clinical studies. The use of allogeneic cells is far more challenging, but may be a promising alternative to use of autologous cells. Moreover, an optimized dosage of cells from an allogeneic source is needed to obtain off-the-shelf tissue engineering products (TEPs). The purpose of this study was to evaluate the efficacy of a TEP composed of undifferentiated ex vivo expanded BM-MSC of allogeneic origin, combined with bone matrix particles in variable doses. A comparative analysis of TEP's bone regenerative properties against its autologous counterpart was performed in an early-stage ONFH preclinical model in mature sheep. Allogeneic BM-MSC groups demonstrated bone regeneration capacity in osteonecrotic lesions equivalent to autologous BM-MSC groups 6 weeks after treatment. Likewise, stimulation of bone regeneration by a low cell dose of 0.5 × 106 BM-MSC/cm3 was equivalent to that of a high cell dose, 5 × 106 BM-MSC/cm3. Neither local nor systemic immunological reactions nor tumorigenesis were reported, strengthening the safety profile of allogeneic BM-MSC therapy in this model. Our results suggest that low-dose allogeneic BM-MSC is sufficient to promote bone regeneration in femoral head osteonecrotic lesions, and should be considered in translation of new allogeneic cell-based TEPs to human clinics. Impact statement Cell therapy and tissue engineering hold promise as novel regenerative therapies for musculoskeletal diseases, and particularly in bone regeneration strategies. In this article, we report the evaluation of the efficacy of an allogeneic cell-based tissue engineering product (TEP) in an early-stage osteonecrosis of the femoral head preclinical model in skeletally mature sheep. Moreover, we demonstrate its bone regeneration capacity and safety in vivo and its equivalence to autologous counterparts. These findings have important implications for the translation of new allogeneic cell-based TEPs to human clinics.

Ischiofemoral Impingement Syndrome: Outcomes of Endoscopic Resection of the Lesser Trochanter.

Ischiofemoral impingement syndrome is a rare clinical entity characterized by chronic groin, buttock or hip pain associated with radiographic evidence of narrowing of the space between the lesser femoral trochanter and the ischial tuberosity. Introduction of magnetic resonance imaging to the clinical practice as well as the establishment of the radiological definition of the abnormal ischiofemoral distance has led to an increasing interest in this condition. Ischiofemoral impingement syndrome is a poorly understood disorder of chronic pain, especially regarding its treatment. The authors present two cases of primary ischiofemoral impingement syndrome successfully treated with a minimally invasive surgical technique. With this endoscopic technique, it was possible to resect the lesser trochanter and restore the ischiofemoral space. Immediate clinical and functional improvement was reported by both patients.

Bernese Periacetabular Osteotomy in a Hip Extra-Articular Resection Followed by Reconstruction Using an Extracorporeal Irradiated Acetabulum Autograft with Megaprosthesis, for Proximal Femur Osteosarcoma in a Pediatric Patient.

Osteosarcoma is the most common primary malignant tumour of bone. The oncologic surgery of a proximal femur osteosarcoma affecting the hip joint can be very challenging. We present an 8-year-old boy with a 5-month history of right hip pain. Radiographs and magnetic resonance imaging (MRI) showed a lytic lesion of the proximal femur extending 13 cm to the diaphysis. Histological evaluation was consistent with high-grade osteoblastic osteosarcoma. After completing chemotherapy we performed an extra-articular resection of the hip. Reconstruction was accomplished by reimplanting the acetabulum after irradiation and modular proximal femur megaprosthesis. Endoprosthetic reconstruction following proximal femur resection is a good treatment alternative achieving good postoperative function. Extra-articular resection of the hip using a periacetabular osteotomy technique enabled us to achieve wide margins and leave an intact posterior column to optimize acetabular reconstruction stability. Extracorporeal irradiation and reimplantation is a valuable treatment option in a situation such as this where allograft geometric fit is a priority. We conclude that an extra-articular resection of the hip, followed by reconstruction with an extracorporeally irradiated acetabulum and a proximal femur modular megaprosthesis, is a useful combined treatment option for malignant lesions involving the hip joint, especially in paediatric patients.

Industrially prefabricated cement spacers: do vancomycin- and gentamicin-impregnated spacers offer any advantage?

BACKGROUND: Industrially preformed antibiotic-loaded cement spacers are useful to facilitate the second stage of two-stage exchange arthroplasty for infected THAs and TKAs. However, whether gentamicin alone or a combination of antibiotics (such as vancomycin and gentamicin) is more effective is not known. QUESTIONS/PURPOSES: We therefore sought to compare industrially prefabricated spacers containing either gentamicin or gentamicin and vancomycin with respect to (1) infection control, (2) complications, and (3) quality of life, pain, and patient satisfaction. METHODS: We performed a review of 51 patients with chronic infections treated at one center using either gentamicin or vancomycin and gentamicin-prefabricated spacers. The former were used exclusively from January 2006 until May 2009, and the latter from June 2009 until July 2011, and there was no overlap. We collected data on demographics, immunologic status (McPherson classification), prosthetic joint infection location, type of prosthesis, microbiologic results, and time between stages. We evaluated the primary outcome of infection control or recurrence after at least 12 months followup. We also recorded complications. Each patient completed a quality-of-life survey, VAS, and a self-administered satisfaction scale. RESULTS: The overall infection control rate was 83% after a mean followup of 35 months (range, 12.4-64.7 months). There were no differences between gentamicin and vancomycin and gentamicin spacers in terms of infection eradication (80 % versus 85 %, respectively; p = 0.73), nor in terms of complications, quality of life, pain, or satisfaction scores. CONCLUSIONS: Prefabricated, antibiotic-loaded cement spacers has been proven effective for infection control in TKAs and THAs but with the numbers available, we did not find any differences between a gentamicin or vancomycin and gentamicin-prefabricated spacer, and therefore, we are unable to validate the superiority of the combination of vancomycin and gentamicin over gentamicin alone. Because of the higher costs involved with vancomycin and gentamicin spacers, and the potential risks of unselective use of vancomycin, further comparative studies are necessary to evaluate their role in the treatment of infected THAs or TKAs. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Evaluation of the effects of platelet-rich plasma (PRP) therapy involved in the healing of sports-related soft tissue injuries.

Musculoskeletal injuries are the most common cause of severe long-term pain and physical disability, and affect hundreds of millions of people around the world. One of the most popular methods used to biologically enhance healing in the fields of orthopaedic surgery and sports medicine includes the use of autologous blood products, namely, platelet rich plasma (PRP). PRP is an autologous concentration of human platelets to supra-physiologic levels. At baseline levels, platelets function as a natural reservoir for growth factors including platelet-derived growth factor (PDGF), epidermal growth factor (EGF), transforming growth factor-beta 1 (TGF-ß1), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (FGF), hepatocyte growth factor (HGF), and insulin-like growth factor (IGF-I). PRP is commonly used in orthopaedic practice to augment healing in sports-related injuries of skeletal muscle, tendons, and ligaments. Despite its pervasive use, the clinical efficacy of PrP therapy and varying mechanisms of action have yet to be established. Basic science research has revealed that PRP exerts is effects through many downstream events secondary to release of growth factors and other bioactive factors from its alpha granules. These effects may vary depending on the location of injury and the concentration of important growth factors involved in various soft tissue healing responses. This review focuses on the effects of PrP and its associated bioactive factors as elucidated in basic science research. Current findings in PRP basic science research, which have shed light on its proposed mechanisms of action, have opened doors for future areas of PrP research.

Lateral subtalar dislocation associated with bimalleolar fracture: case report and literature review.

Subtalar dislocation is an uncommon injury that affects the talocalcaneal and talonavicular joints, with the tibiotalar and calcaneocuboid joints remaining intact. The 4 types of subtalar dislocation are medial, lateral, anterior, and posterior, although the latter 2 are rare. These injuries-especially lateral dislocation-occur as a result of high-energy trauma. Medial dislocation is the most common type, and lateral dislocation is associated with osteochondral fractures of the talus and calcaneus, as well as with open injuries; hence, its worse prognosis. We report the case of a 62-year-old woman diagnosed with lateral subtalar dislocation accompanied by an ipsilateral bimalleolar fracture after a fall downstairs. She underwent emergency reduction of the dislocation under sedation. Surgical treatment of the bimalleolar fracture was delayed 9 days to avoid cutaneous complications. This is the first report of a subtalar dislocation accompanied by a bimalleolar fracture.