Outcomes of Debridement, Antibiotics and Implant Retention (DAIR) for Periprosthetic Joint Infection in a High-Volume Arthroplasty Centre.

Purpose: Prosthetic joint infection (PJI) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) can be a devastating diagnosis. Debridement, antibiotics and implant retention (DAIR) is a preferred treatment modality for acute PJI. A retrospective analysis of infected primary arthroplasties to evaluate the success of DAIR and factors influencing its outcomes. Methods: We retrospectively reviewed all patients who underwent DAIR for PJI at our unit between 2010 and 2018. Patients who underwent revision surgery as an index procedure, arthroscopic washout and those with less than two years of follow-up were excluded. Treatment failure was defined as revision arthroplasty for recurrence of infection within 2 years of the index procedure. Chi-square and Fischer's exact test were used to compare between patient factors and DAIR outcomes. Kaplan-Meier survival curve and log-rank test were used to analyse implant survivorship following DAIR. Results: Of the sixty patients (40 knees, 20 hips) who underwent DAIR, eighteen (13 knees, 5 hips) required revision arthroplasty within 2 years accounting for a success rate of 70%. Predictive factors for revision were American Society of Anaesthesiologist (ASA) score of greater than 2 (p = 0.021), BMI > 35 (p = 0.046), C Reactive protein (CRP) > 200 mg/L (p = 0.007) and Staphylococcus aureus growth (p = 0.012). The five-year survival rate for DAIR was 70%, which remained constant after two years from DAIR. Conclusion: Success rate of DAIR in PJI was 70% which was comparable to similar studies in the literature. ASA > 2, BMI > 35, CRP > 200 and staphylococcus aureus growth were predictors for DAIR failure. Implant survival rate and duration were better following DAIR in early-onset PJI.

Patient compliance with hip precautions 12 weeks following primary elective total hip arthroplasty.

INTRODUCTION: Patients are routinely advised to follow hip precautions following their total hip arthroplasty (THA) surgery. There is lack of evidence regarding compliance with these precautions and when patients return to activities of daily living following their surgery. MATERIALS AND METHODS: We designed a new questionnaire to discover when patients return to their activities of daily living. Two hundred and ninety seven consecutive patients who attended 12 week follow up arthroplasty clinic following their primary elective THA were asked to complete the questionnaire. RESULTS: All patients who attended the follow up clinic at 12 weeks responded to the questionnaire. Only 6.3% (n = 19) of the patients reported that they restricted their daily activities, as prescribed for the full 12 week period, while 50% (n = 148) of patients stopped using prescribed adaptive equipment by 6 weeks after their operation. There were no dislocations recorded among the study group. CONCLUSION: We found that the majority of patients do not adhere to hip precautions advice. They return to their activities of daily living prior to the end of prescription period based on their pain and activity level. Lack of adherence to hip precautions do not predispose to hip dislocation in the immediate post-operative period.

Penetration of topical diclofenac into synovial tissue and fluid of osteoarthritic knees: a multicenter, randomized, placebo-controlled, pharmacokinetic study.

BACKGROUND: Topical diclofenac, a nonsteroidal anti-inflammatory drug, has proven efficacy and safety in the management of osteoarthritis pain. We investigated penetration of topical diclofenac into knee synovial tissue and fluid (primary objective) and evaluated relative exposure in the knee versus plasma (secondary objective). METHODS: In this phase I, double-blind, multicenter study, patients scheduled for arthroplasty for end-stage knee osteoarthritis were randomly assigned 2:1 to 4 g diclofenac diethylamine 2.32% w/w gel (92.8 mg diclofenac diethylamine, equivalent to 74.4 mg diclofenac, per application) or placebo gel, applied to the affected knee by a trained nurse/designee every 12 h for 7 days before surgery. Diclofenac concentrations were measured in synovial tissue, synovial fluid and plasma from samples obtained during surgery ⩾12 h after last application. Treatment-emergent adverse events (TEAEs) were evaluated. RESULTS: Evaluable synovial tissue or fluid samples were obtained from 45 (diclofenac n = 29; placebo n = 16) of 47 patients. All diclofenac-treated participants had measurable diclofenac concentrations in synovial tissue [geometric mean 1.57 (95% confidence interval (CI) 1.12, 2.20) ng/g] and fluid [geometric mean 2.27 (95% CI 1.87, 2.76) ng/ml] ⩾12 h after the last dose. Geometric mean (95% CI) ratio of diclofenac in synovial tissue:plasma was 0.32 (0.23, 0.45) and in synovial fluid:plasma was 0.46 (0.40, 0.54). TEAE rates were similar for diclofenac (55.2%) and placebo (58.8%); none were treatment related. CONCLUSIONS: Topical diclofenac diethylamine 2.32% w/w gel penetrated into the osteoarthritic knee after repeated application and remained detectable in synovial tissue and fluid at the end of the final 12 h dosing cycle.

Impact of counseling and reinforcement by school teachers on behavior change in children: A one -year follow-up study.

INTRODUCTION: School teachers play an important role in instilling positive behavior changes among school children. School children at an early age group of 2-7 years face challenges and need extra support. Utilization of psychological interventions via school teachers for oral health promotion is minimal. The present study was done to determine the impact of counseling and reinforcement by school teachers on children for a follow-up period of 1 year. MATERIALS AND METHODS: A quantitative research on 58 randomly selected children for a follow-up of one year was conducted to determine the prevalence of preoperational characteristics in school children. The tools to determine characters in preoperational children consisted of classical cognitive experiments followed by behavior counseling intervention. The interventional group received reinforcement with school teachers for a follow-up of one year. RESULTS: The assessment of the three characteristics revealed a prevalence of ego centralism, centration, and lack of conservation and reversibility in 84.4%, 89.6%, and 89.6% children, respectively. A significant difference in behavior change was seen in children who received behavior counseling and reinforcement. CONCLUSION: The present study concluded that Piaget's characteristics were consistent for a follow-up period of one year.

The effect of tooth morphology and vertical bracket positioning on resultant stress in periodontal ligament - a three dimensional finite element study.

INTRODUCTION: The purpose of this study is to evaluate the effect of change in vertical placement of bracket and effect of tooth morphology on stress developed on periodontal ligament with the help of three dimensional finite element modeling. METHODS: A three-dimensional model of the maxillary bone, maxillary right central incisor, lateral incisor and canine was designed based on the average dimensions of the anatomy and morphology given by Wheeler's and standard edgewise bracket with Slot of 0.022″ X 0.028″ inch was designed using the finite element method. Brackets were placed on each tooth, on the mentioned labial surface at variable distances from the cusp tip, and a full size archwire was virtually engaged into the bracket, then optimum orthodontic load of 2N is applied and PDL stress were calculated. RESULTS: The lowest stress values were measured as bracket position changes from crest of teeth to the apical direction. By displacing the bracket gingivally from 1.5 to 6 mm, a 16.2% decrease in stress level for central incisor, for lateral incisor the stress level decrease by 25.8% and for canine the stress level decrease by 21.6% thus our study confirms that variation in vertical bracket position results in change in resultant stress in PDL. CONCLUSION: It can be concluded that the variation in the vertical position of the bracket osn different tooth can have an important effect on the stresses developed in the PDL.

Metaphyseal Sleeves for Revision Total Knee Arthroplasty: Good Short-Term Outcomes.

Metaphyseal sleeve prostheses have shown promising results in the management of bone defects at revision TKA. We present a study of their use in aseptic revision TKA. Thirty-five revisions were included in 34 patients with wear or aseptic loosening indicated in 71% of cases. The majority of cases (63%) were AORI grade 2 or greater on the tibia or femur. Knee Society scores were excellent or good in 83% of patients with the same percentage having no or only mild pain. One patient suffered a sleeve-related complication with femoral condylar fractures three years postoperatively; these united with good outcomes. All radiographs were satisfactory; no patient required a further revision. We report good outcomes with the use of metaphyseal sleeves in revision TKA.

Jejuno-jejunal intussusception: An unusual presentation of malignant melanoma.

Jejuno-jejunal intussusception is a rare mode of metastatic melanoma presentation, with only six cases being reported in the English medical literature to date. We present a case of a 55-year-old female who presented to us with features of obstruction. On exploration, it was discovered that she had jejuno-jejunal intussusception, with enlarged blackened mesenteric lymph nodes. Resection and anastomosis were performed. On further histopathological examination, a lesion was found to be a metastatic malignant melanoma.

Factors influencing mortality in patients on antiplatelet agents presenting with proximal femoral fractures.

PURPOSE: To identify factors predicting one-year mortality in patients on clopidogrel presenting with proximal femoral fractures. METHODS: 9 men and 22 women aged 64 to 97 (mean, 81; standard deviation, 8) years who had been taking clopidogrel for ischaemic heart disease (n=15), cerebrovascular disease (n=6), or both (n=10) presented with proximal femoral fractures. The time from injury to operation, type of anaesthesia, treatment method, and postoperative complications were reviewed. One-year mortality was analysed using the Kaplan-Meier curve. Factors predicting one-year mortality were identified. RESULTS: The fracture configurations of the 31 patients included intracapsular femoral neck fracture (n=17), intertrochanteric fracture (n=13), and subtrochanteric fracture (n=1). 30 of the patients underwent hemiarthroplasty (n=16), dynamic hip screw fixation (n=9) or intramedullary hip screw fixation (n=5). The remaining patient underwent conservative treatment owing to metastatic prostate cancer. Of the 30 patients who underwent surgery, clopidogrel was discontinued at least 7 days prior to surgery, with the mean delay to surgery being 8.4 (range, 2-16) days. No patient had excessive blood loss at operation, although 7 patients received a blood transfusion postoperatively. 13 (43%) patients developed postoperative complications. The one-year mortality was 26% (8/31). Univariate analysis showed that factors predicting one-year mortality were spinal anaesthesia (p=0.04), postoperative blood transfusion (p=0.03), postoperative complications (p=0.03), and delay to surgery (p=0.03). Multiple regression analysis showed that delay to surgery (p=0.03) was the only independent predictor of one-year mortality, with a hazard ratio of 1.357 (95% confidence interval, 1.03-1.79). CONCLUSION: Surgery should be performed as soon as possible in medically fit patients having proximal femoral fractures who are taking clopidogrel, as delay to surgery is associated with increased one-year mortality.

Flexion contracture following primary total knee arthroplasty: risk factors and outcomes.

Function and satisfaction after total knee arthroplasty (TKA) are partially linked to postoperative range of motion (ROM). Fixed flexion contracture is a recognized complication of TKA that reduces ROM and is a source of morbidity for patients. This study aimed to identify preoperative risk factors for developing fixed flexion contracture following TKA and to quantify the effect of fixed flexion contracture on outcomes (Oxford knee score 12-60 and patient satisfaction) at 2 years. Pre-, intra-, and postoperative data for 811 TKAs were retrospectively reviewed. At 2 years postoperatively, the incidence of fixed flexion contracture was 3.6%. Men were 2.6 times more likely than women to have fixed flexion contracture (P=.012), and patients with preimplant fixed flexion contracture were 2.3 times more likely than those without to have fixed flexion contracture (P=.028). Increasing age was associated with an increased rate of fixed flexion contracture (P=.02). Body mass index was not a risk factor (P=.968). Incidence of fixed flexion contracture for those undergoing computer navigated TKA was 3.9% compared with 3.4% for those having conventional surgery (P=.711). Patients with fixed flexion contracture had poorer outcomes with a median [interquartile range] Oxford Knee Score of 25 [15] compared with 20 [11] for those without (P=.003) and lower patient satisfaction (P=.036). These results support existing literature for incidence of fixed flexion contracture after TKA, risk factors, and outcomes, indicating that these figures can be extrapolated to a wide population. They also clarify a previously contentious point by excluding body mass index as a risk factor.

Fracture of an Exeter 'cement in cement' revision stem: a case report.

The 'cement in cement' technique for revision hip arthroplasty has become popular in recent years, particularly in relation to polished taper stems. Since 2006 a short Exeter stem with 44 mm offset has been available specifically for this purpose. We report a fracture of such a stem in the absence of trauma 5 years after the revision procedure. The patient had a BMI of 27.8 and the proximal cement mantle gave good support to the stem. The fracture initiated and propagated from the introducer hole on the shoulder of the prosthesis. Macroscopically there was no defect in this area. This may be an unusual case of fatigue failure.

Use of irradiated bone graft for impaction grafting in acetabular revision surgery: a review of fifty consecutive cases.

Impaction bone grafting is a useful technique in the armament of a revision hip surgeon. Traditionally fresh frozen allograft has been used for this technique. However there are concerns about the transmission of viral proteins and prions through this form of allograft. As a result irradiated bone graft has been favoured in some centres. There is no long term series describing the results of impaction bone grafting using irradiated bone. This paper reviews a consecutive series of 50 cases of acetabular revision surgery performed between 1995 and 2001 and followed up over a mean period of 45 months. The preoperative bone defect was graded by the Paprosky classification. There were 2 cases of type 1a, 9 type 2a, 15 type 2b, 7 type 2c, 10 type 3a and 7 type 3b. All cases were followed up clinically and radiologically. Case notes were reviewed for primary prosthesis, operative details and reason for revision. The radiographs were evaluated for signs of bone incorporation, remodelling, loosening and migration of the acetabular component. There were 5 cases of aseptic loosening at the end of the follow up period. One patient had recurrent dislocation and was revised. 20 cases (40%) showed changes suggestive of bone incorporation, while only 3 cases (6%) showed remodelling. Clinically a good or excellent outcome with absence of pain was achieved in 35 patients (70%). The results suggested that acetabular impaction bone grafting using irradiated bone graft is comparable to fresh frozen allograft. The low percentage of remodelling remains a concern and warrants further studies.

A technique of staged lateral release to correct patellar tracking in total knee arthroplasty.

Optimal patellar tracking and component alignment are important in achieving a well-functioning total knee arthroplasty (TKA). The patella is constrained partly by design of the prosthetic trochlear groove, and patellar tracking is governed by a combination of static and dynamic factors. Maltracking may result from excessive or unbalanced tension in the surrounding soft tissues. This article describes a staged progressive lateral release of the patellar retinaculum in TKA, which is classified into 6 stages. Stage 1 transects the deep lateral patellofemoral ligament; stages 2 to 6 extend the lateral patellar incision distally from vastus lateralis to the tibial tubercle. This technique was used in a series of 96 primary TKAs. We report the rates of the various stages of lateral release and the variables that might affect the decision to perform such a release.