Clinically unsuspected orthopedic implants during S. aureus bacteremia do not require additional diagnostic work-up.

PURPOSE: To assess the likelihood of occult infection in patients with clinically unsuspected orthopedic implants during Staphylococcus aureus bacteremia (SAB). METHODS: In a retrospective study in two Dutch hospitals, we included all patients with SAB between 2013 and 2020 with one or more orthopedic implants in whom [18F]FDG-PET/CT was performed. The primary outcome was the percentage of patients who had an orthopedic implant-related infection by S. aureus. We also compared clinical parameters in patients with clinically suspected and unsuspected implants. RESULTS: Fifty-five of 191 (29%) orthopedic implants in 118 SAB patients included had clinical signs of infection. Of all 136 unsuspected implants, 5 (3%, all arthroplasties), showed increased [18F]FDG uptake around the prosthesis on [18F]FDG-PET/CT. The clinical course of these patients without clinically overt infection or relapse of bacteremia during follow-up of a median of 48 months (range 0-48), however, argued against prosthetic joint infection. CONCLUSION: Although orthopedic implants are evidently a risk factor for metastatic infection during SAB, the absence of clinical symptoms obviate the need of additional investigations or prolonged antibiotic treatment.

Empiric antibiotic treatment for periprosthetic joint infections: a national survey in The Netherlands.

Early periprosthetic joint infection (PJI) is generally treated by means of debridement, antibiotics and implant retention (DAIR). Subsequently, empiric antibiotic therapy is commenced directly after surgery which is important for the successful treatment of PJI. The aim of this study is to evaluate current nationwide empiric antibiotic treatment regimens for PJI in the Netherlands. An electronic 15-question survey addressing the empiric antibiotic treatment strategy for PJI following THA or TKA was sent to orthopaedic surgeons in all Dutch hospitals in April 2019. Orthopaedic surgeons active in every single Dutch orthopaedic hospital (n=69) were approached. At least one surgeon in every hospital completed the survey (100% response rate). A protocol dictating the empiric antibiotic treatment following DAIR was used in 87% (60 hospitals). Among all hospitals, 72% (50 hospitals) used antibiotic monotherapy and 28% (19 hospitals) used combination therapy. Cefazolin was the most commonly used regimen in centres opting for monotherapy (42%, 29 hospitals). Similar regimens were used for the empiric treatment of suspected early PJI after revision surgery and for acute hematogenous PJI. In septic patients, combination therapy was preferred (64%). 81% (56 hospitals) incubated tissue biopsies for a minimum of 10 days whereas 16% (9 hospitals) indicated an incubation period of 7 days or less. Even in a small country such as the Netherlands there seems to be no uniformity regarding empiric antibiotic treatment for PJI. Increased uniformity regarding empiric treatment could be an important first step in improving PJI treatment.

Complications and survival of conversion to total hip arthroplasty after failed primary osteosynthesis compared to primary total hip arthroplasty in femoral neck fractures.

INTRODUCTION: Surgical treatment options for patients with an intracapsular fracture of the femoral neck (FFN) are primary osteosynthesis as a femoral head-spearing technique or primary (hemi)arthroplasty. The most common complications after primary osteosynthesis, such as avascular necrosis (AVN) or non-union, can result in conversion to Total Hip Arthroplasty (cTHA). Data concerning complications and survival rates of cTHA in comparison to primary Total Hip Arthroplasty (pTHA) after FFN are limited due to the absence of well-designed studies. METHODS: A multicentre retrospective cohort study was conducted in three Dutch hospitals comparing the rate of postoperative dislocations, periprosthetic fractures, prosthetic joint infections, blood loss during surgery (>1000 mL), postoperative cardiac- and pulmonary complications after pTHA and cTHA in the first year after surgery. As a secondary outcome implant survival of pTHA and cTHA in terms of revision rates was evaluated. RESULTS: In total 548 patients were included (pTHA n = 264 and cTHA n = 284) with a mean follow-up of 5 years (±3.5 SD). No significant differences were found in postoperative complications rates. The revision rate in the pTHA group was 7.2% in comparison to 7.7% in the cTHA group (p = 0.81). No difference in the short-term implant survival was found between both groups (p = 0.81). CONCLUSION: This study showed no significant differences in terms of postoperative complication rates in the first year after pTHA and cTHA in patients with FFN. Also, no significant difference in short-term implant survival of primary and conversion total hip arthroplasty was found.

Shoulder arthroplasty for glenohumeral osteoarthritis: results from a comprehensive survey in Belgium and the Netherlands.

The purpose of this survey in Belgium and the Netherlands was to assess treatment variation in glenohumeral osteoarthritis between experienced and less experienced orthopedic surgeons, and to investigate perioperative treatment after shoulder arthroplasty in a large group of orthopedic surgeons. Orthopedic surgeons specialized in shoulder surgery were invited to complete a survey between November 2013 and February 2015. Seventy-one percent of the approached surgeons com-pleted the survey. Less experienced surgeons (< 6 years) and surgeons from the Netherlands find patient characteristics (e.g. smoking p=0.01) more relevant than more experienced surgeons (≥ 6 years) and surgeons from Belgium. Less experienced surgeons will less likely (p=0.001) perform resurfacing arthroplasty compare to experienced surgeons. The less and the experienced surgeons use similar indications for a reverse shoulder arthroplasty regarding age limit and cuff arthropathy without osteoarthritis. Less experienced surgeon will more likely (p=0.003) prescribe a low molecular weight heparin during the hospital stay after a shoulder arthroplasty. In this survey, we found a decrease in the use of resurfacing arthroplasty and a strong increase in the use of reverse shoulder arthroplasty. Besides, there is little consensus concerning pre-operative planning, patient characteristics, surgical technique, and patient reported outcome measures. Level of evidence: IV.

The Girdlestone situation: a historical essay.

The eponymous term 'Girdlestone situation' originally referred to an excision of the femoral head in case of an acute pyogenic infection of the hip, described by Gathorne Robert Girdlestone in 1945. Over time the procedure and the indication to perform it have significantly changed. This article presents a short biography of Girdlestone with a concomitant report on investigating the evolution of the indication and technique of the Girdlestone situation from the first description up to contemporary literature.

Low conversion rates toward total hip arthroplasty after hemiarthroplasty in patients under 75 years of age.

INTRODUCTION: An intracapsular fracture of the femoral neck is frequent in the elderly. Patients can be treated with either total hip arthroplasty or hemiarthroplasty. There is a continuous discussion about the treatment in elderly patients who are still healthy, active and mentally untroubled. A potential consequence of hemiarthroplasty, especially in the relatively young elderly, could be conversion to total hip arthroplasty. The conversion rate must be acceptable, and clinical outcome must be sufficient to justify the treatment with hemiarthroplasty in this group of patients. This study evaluates the conversion rate of hemiarthroplasty to total hip arthroplasty and clinical outcome in patients under 75 years of age. METHODS: This study identified 248 patients, younger than 75 years at time of operation, with a fracture of the femoral neck treated with hemiarthroplasty. Patient-reported outcome measurements (VAS pain during rest and activity and WOMAC) were assessed by telephone interviews. Furthermore, radiographic evaluation for the presence of acetabular wear was performed. RESULTS: At a follow-up of 5.1 (0.9-9.6) years, the conversion rate was 7.3%. Mean VAS pain in rest was 0.89 (0-10), the mean VAS pain during activity was 2.2 (0-10), and the WOMAC showed a mean of 16.51 (0-64). At time of follow-up, 38.7% of patients had died. Radiographic evaluation of the unrevised group showed in one patient signs of acetabulum wear. CONCLUSION: Hemiarthroplasty in the relatively young elderly after a fracture of the femoral neck demonstrates an acceptable conversion rate. Furthermore, unrevised patients show low complaints of pain. To prevent one conversion to total hip arthroplasty, 13.7 patients should be treated with total hip arthroplasty that will not undergo a conversion at a later stage. Therefore, hemiarthroplasty remains a viable treatment of femoral neck fractures in relatively young patients. There seems to be no space for standardized decision making concerning the choice of treatment. An individual approach is required.

The Pellegrini-Stieda Lesion of the Knee: An Anatomical and Radiological Review.

The Pellegrini-Stieda lesion is a calcification on the medial side of the knee. The origin of this tissue is controversial. The purpose of our study is to investigate the origin of the Pellegrini-Stieda lesion using conventional radiography as to recreate the circumstances in which Pellegrini and Stieda had to study this pathology. Six nonpaired fresh-frozen cadaveric knees were used. A surgical approach to the medial side of the knee was performed using the layered approach. The origin of the gastrocnemius muscle (GM) (n = 3) or the superficial medial collateral ligament (sMCL) (n = 3) were marked with a radio-opaque fluid. X-ray analysis was performed by measuring the distance from the proximal part of the marking to the medial tibial plateau, multilayer views, and comparison to the original X-rays by Pellegrini-Stieda. Two out of three markings in both the GM and sMCL group were matched with the correct structure. The images were digitally processed so that the osseous structures became partly transparent. After overlaying the images, we found a random distribution of the markings. The Stieda/GM group had no overlap of the markings at all. Compared with the original images from the publications by Pellegrini and Stieda, no comparable position could be found between the original lesions and the markings in our specimens. Conventional X-ray of the knee could not reproduce a distinction between the sMCL and GM as origins for the Pellegrini-Stieda lesion as suggested by Pellegrini and Stieda.

Eponymous terms in anterior shoulder stabilization surgery.

Shoulder dislocation and its treatment are probably as old as time. Surgical treatment has gained acceptance recently, especially in recurrent cases. Within roughly the last 100years, numerous treatment strategies have been developed and questions elucidated regarding the entity of shoulder instability. Shoulder instability holds many eponymous terms. By means of literature and historical research, we present the biographical background of some common eponymous terms and the original publication on which those terms are based. We describe the Perthes lesion, Bankart lesion and repair, Hill-Sachs lesion, Bristow-Latarjet procedure and Eden-Hybbinette procedure. Shoulder instability has been recognized and treated for many centuries. Before the invention of X-rays and the ability to intervene surgically, empirical reduction and time were the only feasible treatment options. Understanding of the pathophysiology of this problem and its corresponding treatment has kept increasing since the 19th century. The originators involved still have their name attached to the different signs and procedures. LEVEL OF EVIDENCE: IV.

[A motorcyclist with hematomas and tingling in his leg]. / Motorrijder met hematomen en tintelingen in het been.

A 30-year-old man presented with recurrent hematomas and tingling in his left leg, caused by a large femoral neck osteochondroma that induced multiple muscle ruptures and compressed the ischiadic nerve. There were no radiological signs of malignant transformation and symptoms disappeared without intervention. Hence, we chose a 'wait and see' approach instead of surgical removal of the osteochondroma.

[A locked knee without previous trauma]. / Knie op slot zonder voorafgaand trauma.

A 22-year-old female presented at our hospital with a spontaneous extension deficit of the left knee. Examination revealed a luxation of the semitendinosus tendon under an osteochondroma on the posteromedial side of the proximal tibia. The tendon was repositioned by flexion and endorotation of the knee. Subsequently, the osteochondroma was surgically resected to prevent recurrence of the complaints.

[A motorcyclist with hematomas and tingling in his leg]. / Motorrijder met hematomen en tintelingen in het been.

A 30-year-old man presented with recurrent hematomas and tingling in his left leg, caused by a large femoral neck osteochondroma that induced multiple muscle ruptures and compressed the ischiadic nerve. There were no radiological signs of malignant transformation and symptoms disappeared without intervention. Hence, we chose a 'wait and see' approach instead of surgical removal of the osteochondroma.

The Bristow-Latarjet procedure, a historical note on a technique in comeback.

The Bristow-Latarjet procedure is a well-known surgical technique designed to treat shoulder instability. In this procedure, the coracoid process is transferred to the glenoid rim, to serve as augmentation of an associated bony defect. Because long-term results following a soft tissue procedure (Bankart repair) reveal that up to 21 and 33 % of the patients might experience recurrent instability and with the advent of the arthroscopic coracoid transfer, there is renewed interest in this procedure to treat shoulder instability. The aim of this study is to provide a historical overview, with emphasis on the original inventors Bristow and Latarjet, the complications and following modifications regarding the surgical approach, the coracoid transfer and the arthroscopic technique. Level of evidence V.

Proximal tibiofibular dislocation: a case report and review of literature.

An isolated dislocation of the proximal tibiofibular joint is uncommon. The mechanism of this injury is usually sports related. We present a case where initial X-rays did not show the tibiofibular joint dislocation conclusively. It was diagnosed after comparative bilateral AP X-rays of the knees were obtained. A closed reduction was performed and followed by unrestricted mobilization after 1 week of rest. A review of the literature was conducted on PubMed MEDLINE. Thirty cases of isolated acute proximal tibiofibular joint dislocations were identified in a search from 1974. The most common direction of the dislocation was anterolateral, and common causes were sports injury or high velocity accident related. More than 75 % of the cases were successfully treated by closed reduction. Complaints, if any, at the last follow-up (averaging 10 months, range 0-108) were, in the worst cases, pain during sporting activities. We advise comparative knee X-rays if there is a presentation of lateral knee pain after injury and diagnosis is uncertain. Closed reduction is usually successful if a dislocation of the proximal tibiofibular joint is diagnosed. There is no standard for after-care, but early mobilization appears safe if there are no other knee injuries.

Long-Term Alendronate Use Not without Consequences?

A previously unknown side effect of biphosphonate use is emerging. In a specific patient group on long term biphosphonate therapy stress femur fractures seem to occur. The typical presentation consists of prodromal pain in the affected leg and/or a discrete cortical thickening on the lateral side of the femur in conventional radiological examination or the presentation with a spontaneous transverse subtrochanteric femur with typical features. We present three cases of this stress fracture in patients on bisphosphonate therapy. One of these patients suffered a bilateral femur fracture of the same type. In our opinion, in patients on bisphosphonate therapy who present with a spontaneous femur fracture, seizing therapy is advisable. In bilateral cases preventive nailing should be considered.