Prevalence and Impact of Unexpected Positive Intraoperative Cultures in Total Hip or Knee Revision Surgery.

BACKGROUND: Our aim was to evaluate the prevalence and impact of unexpected positive intraoperative cultures (UPICs) on the outcome of presumed aseptic total knee and hip revision surgery. METHODS: Data regarding patients who underwent elective total hip or knee revision surgery from January 2003 to July 2017 due to preoperatively presumed aseptic reasons was retrospectively reviewed. Partial revisions and patients who had follow-ups below 60 months were excluded from the study. In all surgeries, at least 3 intraoperative samples were taken for microbial culture. Failure was defined as the need for rerevision due to any cause at 5 years and/or the need for antibiotic suppressive therapy. Overall, 123 total hip and 431 total knee revisions were eligible for the study. All cases had at least a 5 years follow-up. RESULTS: There were 420 cases (75.8%) that had all cultures negative, 108 (19.5%) had a single UPIC, and 26 (4.7%) had either ≥2 UPICs for the same microorganism or 1 UPIC for a virulent microorganism. This latter group was not associated with a significantly higher failure rate (2 of 26, 7.7%) compared to those in the aseptic group (54 of 528, 10.2%). Revisions performed within the first 24 months after primary implantation had a higher 5-years rerevision rate (19.3 versus 8.4%, P = .01), mainly attributable to aseptic causes. CONCLUSIONS: Total hip and knee revisions with UPICs were not significantly associated with a higher rerevision risk at 5 years. Those revisions performed within the first 24 months after primary arthroplasty had a higher rate of any-cause failure.

Contribution of the BioballTM head-neck adapter to the restoration of femoral offset in hip revision arthroplasty with retention of a well-fixed cup and stem.

PURPOSE: Failure to restore the femoral offset of the native hip is a potential cause of dysfunctional hip arthroplasty. The aim of this study was to report our experience of using a modular head-neck adapter in revision THA, specifically analyzing its usefulness as a tool to correct a slightly diminished femoral offset. MATERIALS AND METHODS: This was a retrospective single-center study including all hip revisions performed at our institution from January 2017 to March 2022 where the BioBallTM head-neck metal adapter was used. The preoperative and one year follow-up modified Merle d'Aubigné hip score was used to evaluate functional outcomes. RESULTS: Of a total of 34 cases included for revision, the head-neck adapter system was used specifically in six patients (17.6%) to increase femoral offset, retaining both the acetabular and femoral components. In this subgroup of patients, mean offset decrease after primary THA was 6.6 mm (4.0-9.1), equivalent to a mean 16.3% femoral offset reduction. The median modified Merle d'Aubigné score went from 13.3 preoperatively to 16.2 at one year follow-up. CONCLUSION: The use of a head-neck adapter is a safe and reliable procedure that may allow the surgeon to easily correct a slightly diminished femoral offset in a dysfunctional THA without the need to revise well-fixed prosthetic components.

Can the intra-operative measurement of the diameter of the femoral head help surgeons to choose the best size of the acetabular cup?

PURPOSE: We hypothesized that the intra-operative measurement of the femoral head may increase the accuracy of the acetabular cup size optimal selection in total hip arthroplasty (THA). The purpose of this clinical research was to analyze the correlation between the estimated cup size from intra-operative measurement of the femoral head and the pre-operative templated cup size. METHODS: A prospective observational single-center study was conducted from June 2019 to January 2020 including primary THA (n = 100). All cases were pre-operatively templated. The measurement of the anterior-posterior diameter of the femoral head was routinely intra-operatively performed. Any definitive implanted cup was considered as "oversized" when the size was > 4 mm than the diameter of the native head. RESULTS: The median (interquartile range) size of the implanted cup, pre-operative planned cup size, and diameter of the femoral head were measured 52 (50-54) mm, 50 (48-54) mm and 49 (45-51) mm, respectively. Pre-operative planned size cup accurately predicted the implanted cup or differed in only one size (2 mm) in 77 (78%) cases. Otherwise, intra-operative femoral head measurement method accurately predicted the implanted or differed in only one size (2 mm) in 51 (87%) cases (p = 0.097). CONCLUSION: The intra-operative femoral head measurement is a simple and reliable tool to help the surgeons choose the best size of the acetabular cup and is as reliable as the pre-operative templating in order to avoid cup oversizing in THA. Utmost caution is warranted whenever the cup reamer is > 4 mm than the anterior-posterior diameter of the native head.

Fluorescent tetracycline bone labeling as an intraoperative tool to debride necrotic bone during septic hip revision: a preliminary case series.

A plausible cause of persistent infection after septic hip revision may be the presence of nonviable osteomyelitic bone. Since surgical excision of these necrotic fragments is often challenging, the use of fluorescent tetracycline bone labeling (FTBL) as an intraoperative tool may pose an additional assessment aid to provide a visual index of surgical debridement. Methods: We present a single-center study performed in a university hospital from January 2018 to June 2020, in which all consecutive cases of chronic hip periprosthetic joint infection (PJI) undergoing revision using FTBL were retrospectively reviewed. In all cases, the patient was under treatment with tetracyclines at the moment of the revision surgery. During the surgery, all bone failing to fluoresce was considered nonviable and thus removed and sent for both culture and histology. Results: We include three cases in which the FTBL technique was used. In all cases, the histopathological examinations of the nonfluorescent removed bone were consistent with chronic osteomyelitis. Conclusion: The intraoperative use of FTBL successfully aided the surgeon to detect the presence of nonviable bone in all the presented cases of chronic prosthetic hip infection.

Outcomes of hip arthroplasty with concomitant hardware removal: influence of the type of implant retrieved and impact of positive intraoperative cultures.

INTRODUCTION: The impact of residual internal fixation devices on subsequent procedures about the hip has not been clearly well defined. The objective of the current study is to evaluate the outcome of hip arthroplasty after hardware retrieval as a one-stage replacement, to analyze possible differences related to the type of removed implant, and to assess the impact of unexpected intraoperative cultures during implant retrieval. MATERIALS AND METHODS: We present a retrospective study including all those cases undergoing hip arthroplasty with concomitant hardware removal (cannulated screws, intramedullary nail, or dynamic hip screw) from 2005 to 2018. We evaluated demographics, intraoperative cultures, early infection rate, and other complications. RESULTS: A total of 55 cases were included in the study. The median time between the implant surgery and the hip arthroplasty was 113 days. The removed devices included 6 cannulated screws, 34 intramedullary nails, and 15 dynamic hip screws. Up to 74.5% of the failed osteosynthesis belonged to intertrochanteric femoral fractures. Dislocation rate was 9.1% (1.8% requiring revision surgery), 25.5% of the cases needed further new surgeries after the hip arthroplasty, and 49.1% died during the follow-up period. Any-cause revision surgery and mortality rates were significantly increased after intramedullary nail removal. Intraoperative cultures were performed in 46 cases, and in 9 (16.4%), there was bacterial contamination: 6 cases (10.9%) presented one single positive culture and 3 (5.5%) presented ≥ 2 positive cultures for the same microorganism. A total of five cases (9.1%) presented early prosthetic joint infection that required debridement. None of these five cases had presented positive cultures at the implant removal. CONCLUSION: According to our results, hip arthroplasty with concomitant hardware removal is related to a high 5-year mortality rate, mainly when intramedullary nail is retrieved. Whereas a high risk of early prosthetic joint infection is associated, it seems not to be related to the elevated presence of unexpected positive cultures.

The use of a "rim cutter" device and a flanged cup for improving the mantle of the acetabular component of a cemented Exeter total hip arthroplasty.

A retrospective study was performed to evaluate the cement mantle in two groups of patients treated with the acetabular components of cemented Exeter total hip arthroplasties (THAs). Two groups of 20 patients were compared: Group 1 received non-flanged acetabular cemented cups (Contemporary, Stryker) and Group 2 received flanged acetabular cemented cups (X3 Rim Fit, Stryker). Cups in Group 2 were implanted after using a rim cutter device. Group 2 showed better penetration of cement in zone 1 (10.76 mm compared with 2.93 mm; p = 0.008) and a thicker cement mantle in zone 1 (3.57 mm compared with 2.89 mm; p = 0.04). More cups in Group 2 had a cement mantle thickness less than 3 mm (30 % in Group 1 compared with 70 % in Group 2; p = 0.0039). No other radiological differences were observed. These results favor the use of a rim cutter device and flanged cup to improve the cement mantle for the acetabular components of cemented Exeter THAs. However, the improvements were less than expected. In view of the results of previous studies, further research is therefore needed to assess the value of this approach in improving the acetabular cement mantle.

Radiography versus multidetector computed tomography in assessing graft integration after acetabular reconstruction.

PURPOSE: To compare radiography with multidetector computed tomography (MDCT) in the evaluation of graft integration following acetabular reconstruction for failed total hip arthroplasty (THA). METHODS: Records of 5 men and 6 women aged 60 to 78 (mean, 71.8) years who underwent acetabular reconstruction using structural allografts for severe acetabular deficiency secondary to aseptic loosening (n=9) or septic loosening (n=2) were reviewed. The mean survival time of the THA was 136.4 (range, 12-360) months. Acetabular defects were classified as IIC (n=2), IIIA (n=3), or IIIB (n=6). Structural allografts were fixed with impaction followed by a reinforcement ring (n=10), an antiprotrusio cage (n=2), and/or an oblong cup (n=1) with gentamicineloaded cement. Cup loosening, graft integration, and graft resorption were evaluated using radiography. In addition, graft integration was evaluated using MDCT. RESULTS: At a mean follow-up of 4.2 (range, 2-11) years, the survival of the acetabular reconstruction was 90.9%. No patient had any signs of infection. One patient underwent reoperation 22 months later for dislocation secondary to abductor deficiency caused by nonunion of the trochanteric fracture. According to radiography, all patients had graft integration. One patient had definitive and another had possible cup loosening. Four patients had minor graft resorption. According to MDCT, graft integration was complete in only one patient, partial >50% in 3, partial <50% in 4, and absent in 2. CONCLUSION: MDCT is more accurate than radiography in evaluating graft integration following acetabular reconstruction.

Calidad de vida y supervivencia tras el tratamiento quirúrgico de las fracturas metastásicas del fémur / Quality of life and survival after surgical treatment of metastatic femoral fractures

Fundamento y objetivo: Analizar los resultados obtenidos en tratamiento quirúrgico de pacientes con fractura de fémur secundaria a enfermedad metastásica ósea, sobre la base de la calidad de vida y la supervivencia. Material y método: Se efectuó un estudio transversal y prospectivo en un período de 15 meses, en el que se incluyeron 20 fracturas de fémur en 19 pacientes, que correspondieron a 10 fracturas inminentes (FI) y 10 fractura establecidas (FE). Como variables de resultado se analizaron las complicaciones asociadas, el tipo de deambulación en el momento del alta hospitalaria y los cambios en la escala de Karnofsky respecto al ingreso. Se registró asimismo la mortalidad perioperatoria y la supervivencia tras la intervención. Resultados: El tratamiento quirúrgico realizado fue osteosíntesis (72%) y protetización (28%). Como complicaciones destacaron: 1 fallecimiento perioperoperatorio y 1 fallo del sistema de osteosíntesis. Respecto a la situación al ingreso, se observó una mejoría en la calidad de vida, sobre la base de la escala de Karnofsky (p=0,017). La supervivencia tras la cirugía fue de 2 meses en el grupo de pacientes con FI y de 5 meses en el grupo de las FE (p=0,816).Conclusiones: Los pacientes intervenidos por fractura secundaria a metástasis ósea en el fémur presentaron una mejoría de calidad de vida según la escala de Karnofsky. A pesar de tratarse de un grupo de pacientes con una reducida supervivencia, el control del dolor y la mejoría funcional justifican el procedimiento (AU)

Background and objectives: To analyze the results of the surgical treatment of proximal femoral fractures secondary to metastatic bone disease, in terms of quality of life improvement and survival. Results: Surgical procedures performed were osteosynthesis (72%) and femoral arthroplasty (28%). With regard to complications, 1 patient died during the intra-operatory period and there was 1 failure of ostesyntesis that required re-operation. There was an improvement in the quality of life measured according to the Karnofsky scale after the surgery (P=.017). Survival after surgery was 2 months in the group of patients with impending fracture and 5 months in the group of patients with established fracture (P=.816).Conclusions: Patients who underwent surgery for a femoral fracture secondary to a metastatic disease showed an improvement in the quality of life, according to the Karnofsky scale. Although they represent a group of patients with a short survival, the control of pain and functional improvement justifiy the procedure (AU)

[Quality of life and survival after surgical treatment of metastatic femoral fractures]. / Calidad de vida y supervivencia tras el tratamiento quirúrgico de las fracturas metastásicas del fémur.

BACKGROUND AND OBJECTIVES: To analyze the results of the surgical treatment of proximal femoral fractures secondary to metastatic bone disease, in terms of quality of life improvement and survival. MATERIAL AND METHOD: A transversal prospective study was carried out during a period of 15 months in which 20 fractures of femur from 19 patients were included, corresponding to 10 imminent fractures (IF) and 10 established fractures. Assessed final outcomes were associated complications, walking type at discharge and change in Karnofsky's scale after surgery. Mortality and survival after operation were also registered. RESULTS: Surgical procedures performed were osteosynthesis (72%) and femoral arthroplasty (28%). With regard to complications, 1 patient died during the intra-operatory period and there was 1 failure of ostesyntesis that required re-operation. There was an improvement in the quality of life measured according to the Karnofsky scale after the surgery (P=.017). Survival after surgery was 2 months in the group of patients with impending fracture and 5 months in the group of patients with established fracture (P=.816). CONCLUSIONS: Patients who underwent surgery for a femoral fracture secondary to a metastatic disease showed an improvement in the quality of life, according to the Karnofsky scale. Although they represent a group of patients with a short survival, the control of pain and functional improvement justifiy the procedure.

Axillary arterial thrombosis secondary to anterior shoulder dislocation.

We report the case of a 59-year-old male patient who returned to the Hospital with severe pain in the right upper arm, 9 hours after reduction of an anterior dislocation of the right shoulder. A thrombosis of the axillary artery was quickly diagnosed and the rapid treatment allowed revascularisation in the arm without any major consequences.