Two-Stage Revision Protocol in Multidrug Resistant Periprosthetic Infection Following Total Hip Arthroplasty Using a Long Interval Between Stages.

We retrospectively reviewed the medical records of 31 patients with periprosthetic hip infections attempting to evaluate the outcome of a two-stage revision protocol characterized by prolonged interim period (mean=9.2 months, range 8-12 months) prior to the final re-implantation. In 3 cases (9.6%) the 1st stage was repeated after a mean period of 12.3 weeks due to relapse of infection. Five spacer dislocations occurred, not affecting the final clinical outcome after reimplantation, as evaluated by the Harris Hip Score. No protrusions or additional acetabular bone loss was noticed. Our proposed protocol is a simple, safe, efficient and reproducible treatment approach that may be successfully utilized predominantly when dealing with multidrug resistant pathogens.

Reverse shoulder arthroplasty for the treatment of three and four part fractures of the proximal humerus in patients older than 75 years old.

Reverse shoulder arthroplasty is an attractive alternative option in treating three- or four-part fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary reverse shoulder arthroplasty of three- or four-part fractures of the proximal humerus in patients older than 75 years old. Between 2008 and 2010, 29 consecutive patients with a three- or four-part fracture of the proximal humerus undergoing a reversed shoulder prosthesis were included. There were 16 women and 13 men, with a mean age of 81 years (range 78 to 85). The dominant arm was involved in 18 patients (62%). All of the operations were carried out within 10 days of the injury. The patients were followed up for a mean of 26 months (range 10 to 36). The mean postoperative Constant-Murley score at the end of the follow-up period for each patient (age- and gender-matched) was 73.3% (range 58 to 92%). The mean Constant score was 75% in the group of patients with fixation of the tuberosities and 72.3% in the patients with no fixation of the tuberosities (p = 0.06). There was no significant difference in Constant score between patients who were operated by the fifth day after the fracture and patients who had an operation between the sixth and tenth day after the injury (Constant score of 74% and 71%, respectively, p = 0.07). Complications occurred in 12 patients. One patient sustained a fracture of the acromion intraoperatively. Four patients (13.8%) developed heterotopic ossification. One had a nontraumatic anterior dislocation due to wrong retroversion of the glenoid component. Scapular notching was observed in six shoulders (20.6%).

Demographics, clinical characteristics and predictive factors for total knee or hip replacement in patients with rheumatoid arthritis in Greece.

OBJECTIVES: This paper aims to study the prevalence of total knee and hip replacements in Greek patients with rheumatoid arthritis (RA) and to identify possible predictive factors for future total hip or knee replacement. METHODS: A retrospective medical record review was performed in 750 RA patients who were recruited during 1994 to 2008 in a single Greek medical centre. Of the reviewed patients, 489 with a minimum follow-up duration of 1 year were enrolled in the study. The occurrence of total hip or knee replacement was used as the primary outcome variable in the predictive analysis. RESULTS: Total hip or knee replacement associated with RA was performed in 21 patients (4.3%). Total disease duration was the most significant factor associated with increased likelihood of total joint replacement. Erythrocyte sedimentation rate (ESR) at baseline examination was positively associated with subsequent knee or hip joint replacement (OR=1.023, 95%CI 1.005-1.04). Inadequate response to treatment was associated with a 3.12-times higher likelihood of joint replacement (95%CI, 1.28-7.58). The patients who underwent total hip or knee replacement had significantly higher ESRs and DAS 28 levels (p<0.046 and p<0.002, respectively) after the first year of follow-up. CONCLUSIONS: The identification of factors associated with total joint hip or knee replacement can improve pharmacological treatment to maintain function and prevent destruction of the affected joints. Longer disease duration and inadequate response to treatment after the first year of follow-up increases the likelihood ratio for total joint replacement during the course of disease in Greek RA patients.

Postoperative spinal infection mimicking systemic vasculitis with titanium-spinal implants.

BACKGROUND: Secondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies. CASE DESCRIPTION: A 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection. LITERATURE REVIEW: Systemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition. PURPOSES AND CLINICAL RELEVANCE: Our purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery.