Periprosthetic joint infection of a total hip arthroplasty with Candida parapsilosis.

INTRODUCTION: Fungal periprosthetic joint infection (PJI) is a disruptive and complex complication of joint arthroplasty. We present a case of a fungal PJI with Candida parapsilosis after a total hip arthroplasty (THA). PRESENTATION OF CASE: A 73-year-old woman with a history of ovarian cancer with peritoneal metastases, was treated with a THA, due to symptomatic arthritis of the right hip. One month after surgery, she had difficulties walking. Inflammatory parameters were mildly increased. Aspiration of a subcutaneous abscess diagnosed Candida parapsilosis. A two-stage revision arthroplasty without spacer was performed. During a six-week prosthesis-free interval, intravenous fluconazole 400 mg was given. After reimplantation, fluconazole was continued for two weeks intravenously and life-long perorally. Follow-up of the patient after six months showed no recurrence of infection. DISCUSSION: This case revealed that when PJI is suspected, a low treshold for joint aspiration is important. Two-stage revision with systematic antifungal therapy is the preferred treatment of fungal PJI. Our case demonstrated a good result with a prosthesis-free interval. Fluconazole is the preferred antifungal treatment and it should be applied for at least six months or longer. CONCLUSION: To our knowledge, this is the first case of a fungal PJI with Candida parapsilosis after a THA treated with a two-stage revision arthroplasty without spacer and a life-long fluconazole treatment.

Rotator cuff repair with all-suture anchors: a midterm magnetic resonance imaging evaluation of repair integrity and cyst formation.

BACKGROUND: This study investigated the feasibility and safety of all-suture anchors in arthroscopic rotator cuff repair. METHODS: All patients were diagnosed with a rotator cuff tear by ultrasound or magnetic resonance imaging (MRI). Patients with partial tears, massive tears, subscapularis tears, or previous shoulder surgery, were excluded. MRI and clinical outcome were investigated in all patients at 1.58 years (range, 1.0-2.0 years) after rotator cuff repair with all-suture anchors (prospective case series). Integrity of the cuff repair, cyst formation (encapsulated fluid signal around the anchor), ingrowth of the bone into the anchor, and integrity of the bone tunnel border were evaluated for 47 anchors. Clinical results were evaluated using the Constant-Murley score. RESULTS: An MRI evaluation was performed in 20 patients at 1.58 years (range, 1.0-2.0 years) after rotator cuff repair with all-suture anchors. MRI evaluation showed a very small rim of fluid around 10% of the anchors. None of the anchors showed cyst formation with fluid diameter more than twice the anchor diameter. In approximately 90% of the anchors, no fluid could be detected between the anchors and the edge of the bony tunnel. Full rotator cuff integrity was seen in 19 patients. Only 1 patient sustained a retear. Clinical results comparable with an arthroscopic rotator cuff repair using classic anchors were seen. CONCLUSIONS: This prospective clinical cohort study shows promising early radiographic and clinical results after arthroscopic rotator cuff repair using all-suture anchors.

Correction to: Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis.

Unfortunately, one of the co-author's name was missed in the original online publication of this article. The name should be included as sixth author in the author group.

Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis.

PURPOSE: To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft. METHODS: Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12®. 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations. RESULTS: In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture. CONCLUSION: In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture. CLINICAL RELEVANCE: the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively. LEVEL OF EVIDENCE: I.

The anterior cruciate ligament: a study on its bony and soft tissue anatomy using novel 3D CT technology.

PURPOSE: The purpose of this study is twofold: first, to visualize both the tibial and femoral bony insertion surfaces and second, to describe the anterior cruciate ligament (ACL) geometrically, using novel 3D CT imaging. In addition, new concepts of best-fit cylinder and central axis are introduced and evaluated. METHODS: Eight unpaired knees of embalmed cadavers were used in this study. Following the dissection process, the ACL was injected with a contrast medium for CT imaging. The obtained CT images in extension, 45°, 90° and full flexion were segmented and rendered in 3D allowing morphological and morphometric analysis of the ACL. Anatomical footprint centres, femoral and tibial footprint surface area, best-fit ACL-cylinder intersection area, best-fit ACL-cylinder/footprint coverage ratio, best-fit ACL-cylinder central axis projections at the tibial and femoral footprint in the four positions were used to describe the anatomy of the ACL, based on the Bernard, Hertel and Amis grid. RESULTS: Based on these parameters, with the best-fit cylinder representing the bulk of the ACL, a changing fibre-recruitment pattern was seen with a moving position of the central axis from posterior to anterior on the femoral and tibial footprint, going from extension to flexion. Furthermore, the numerical data show an increase in tibial footprint coverage by the best-fit cylinder through the ACL when the knee is progressively flexed, whereas an inverse relationship was seen on the femoral side. CONCLUSION: This study is the first to describe the detailed anatomy of the human ACL with respect to its course and footprints using a 3D approach. It confirms the large difference and inter-patient variability between the tibial and femoral footprint area with the former being significantly smaller. The best-fit cylinder concept illustrates the recruitment pattern of the native ACL where in extension the postero-lateral fibres are recruited and in flexion rather the antero-medial bundle, which can be valuable information in reconstructive purposes. The best-fit cylinder and central axis concept offers additional insights into the optimal tunnel placement at the tibial and femoral footprint in order to cover the largest portion of the native ACL soft tissue, aiming for optimal ACL reconstruction.

Custom-made lateral femoral hemiarthroplasty for traumatic bone loss: A case report.

We report the case of a 32-year-old male patient involved in a road traffic accident in which he sustained a grade II open supra- and intercondylar fracture of the left distal femur with substantial bone loss of the lateral femoral condyle and trochlea (AO classification type 33 C3). Normal knee function was no longer possible, as the patella was trapped within the bony defect. Existing reconstructive options such as unicondylar osteoarticular allograft, arthrodesis, and arthroplasty were considered. However, as all these techniques present significant disadvantages, particularly in young and active patients, a custom-made lateral hemiarthroplasty was designed and implanted as an alternative treatment. Follow-up at 24 months revealed an excellent, pain-free level of function and radiographs showed no signs of implant loosening or migration. This technique offers the most anatomical means of reconstruction with maximal preservation of the bone stock, thereby better facilitating any revisions that may be necessary in the future. This is an experimental technique reserved for rare indications, and currently has no long-term follow-up results associated with its use. Additional research is therefore needed before widespread adoption of this technique can take place.

Surgical management of anterior cruciate ligament injuries in Belgium anno 2013.

BACKGROUND: Anatomic ACL surgery, including double bundle ACL reconstruction, has been investigated widely. The purpose of this study was to gain insight in the currently used surgical management of anterior cruciate ligament injuries amongst Belgian orthopaedic surgeons. METHODS: A survey consisting of epidemiological questions, ACL surgery related questions and questions concerning rehabilitation was submitted to all members of the Belgian Knee Society. RESULTS: Anatomic single bundle ACL repair with transportal femoral tunnel drilling, using an autologous hamstring graft fixed with a cortical suspension system proximal and an interference screw distal is currently the most common technique. The surgery is usually performed under general anesthesia with a one-night stay in the hospital. Postoperatively a hinge brace is mostly used. CONCLUSION: Although much research concerning double bundle ACL surgery is performed, only few surgeons perform this technique. Most surgeons perform an anatomic single bundle repair. This is in accordance with the current knowledge regarding cost effective care. Performing this procedure in day care with the aid of loco-regional anesthesia and avoidance of a hinged brace can help to reduce the cost for the healthcare system without compromising the outcome.

Fracture of the Tibial Baseplate in Bicompartmental Knee Arthroplasty.

Introduction. Bicompartmental knee arthroplasty (BKA) addresses combined medial and patellofemoral compartment osteoarthritis, which is relatively common, and has been proposed as a bridge between unicompartmental and total knee arthroplasty (TKA). Case Presentation. We present the case report of a young active man treated with BKA after unsuccessful conservative therapy. Four years later, loosening with fracture of the tibial baseplate was identified and the patient was revised to TKA. Discussion. Although our case is only the second fractured tibial baseplate to be reported, we believe that the modular titanium design, with two fixation pegs, is too thin to withstand daily cyclic loading powers. Light daily routine use, rather than high-impact sports, is therefore advised. Failures may also be related to the implant being an early generation and known to be technically complex, with too few implant sizes. We currently use TKA for the treatment of medial and patellofemoral compartment osteoarthritis.

The lateral tibial tunnel: does it allow for adequate fixation in ACL surgery?

UNLABELLED: The purpose of this cadaver study about the ACL graft was to compare a "Lateral Tibial Tunnel" (LTT) and a "classic, anteroMedial Tibial Tunnel" (MTT), as to fixation strength and mode of failure. Ten pairs of fresh frozen human proximal tibias were used. In one of both tibias a classic anteromedial tunnel was used, versus a lateral tibial tunnel in the contralateral knee. Autologous doubled semitendinosus and gracilis tendons were fixed in the tunnels. A maximum load to failure test was performed to determine the stiffness and the strength of the graft-tibia complex. CONCLUSION: for none of the measurements was there any significant difference between both tunnels. The tibial fixation strength of a human autologous doubled hamstring graft in ACL surgery is similar, whether a lateral or an anteromedial tibial tunnel is used. This is the first study investigating fixation strength of an ACL graft in a lateral tibial tunnel.

Revising the well-fixed, painful resurfacing using a double-mobility head: a new strategy to address metal-on-metal complications.

Isolated revision of the femoral component of hip resurfacings to metal-on-metal (MoM) total hip arthroplasties has shown inferior results. We present a case series of well-fixed, painful MoM hips with elevated chromium and cobalt levels. An isolated femoral revision using a noncemented femoral component and a double-mobility head was performed. Patients were followed up for 6 months and showed excellent improvements in visual analog score and Hip dysfunction and Osteoarthritis Outcome Score (HOOS). Cobalt and chromium levels dropped at 6 weeks and were normal at 6 months. Although our follow-up is short, we feel that it is important to highlight this as a potential treatment strategy. This revision is less aggressive than traditional methods, eliminates the concerns from MoM bearings, and results in a stable construct.

The lateral tibial tunnel in revision anterior cruciate ligament surgery: a biomechanical study of a new technique.

PURPOSE: To evaluate the cortical entry point and the length of a revision lateral tibial tunnel (LTT) in a human cadaveric study and to investigate knee stability after a revision anterior cruciate ligament (ACL) reconstruction with an LTT. METHODS: Ten human cadaveric knee specimens were used to perform a preliminary investigation. Twenty-two human proximal tibias were used to compare the length of a revision LTT with a classical medial tibial tunnel (MTT). Another 5 human cadaveric knees were used to investigate knee stability after a revision LTT and to compare it with a primary ACL repair with an MTT performed in the same knees. Stability was evaluated with computer navigation. RESULTS: An LTT is statistically significantly longer (45.0 mm) than an MTT (35.2 mm) (P < .001). There was no evidence of a length difference between the intact bone tube length of a revision LTT (36.5 mm) and an MTT. For nearly all measurements, the difference between the ACL repair with an MTT and the revision surgery with an LTT was not only nonsignificant but also small in magnitude. Only for internal rotation at 30° of knee flexion and for internal rotation in extension was a significant difference detected (P = .029 and P = .044, respectively). CONCLUSIONS: An LTT can easily be drilled and provides a bony tunnel that is statistically significantly longer than an MTT. A revision LTT has an intact bone tube as long as that of a primary MTT. Similar stability is obtained after revision ACL surgery with an LTT compared with a primary ACL repair with a standard MTT. CLINICAL RELEVANCE: LTT placement is a new technique for ACL revision surgery that can help to overcome problems related to tunnel enlargement in the distal part of the tibial tunnel.

ACL repair with a single or double tunnel: a comparative laboratory study of knee stability using computer navigation.

The purpose of the study was to investigate the biomechanical differences between single bundle (SB), single tunnel-twisted hamstring graft (ST-TG) and double bundle (DB) reconstruction of the anterior cruciate ligament (ACL), using computer navigation for data acquisition. Anterior translation in the medial compartment was corrected to near normal levels at 30 degrees and 90 degrees with all techniques. Anterior translation in the lateral compartment was corrected to near normal levels at 30 degrees and 90 degrees. However, the ST-TG and the DB were overcorrected to below-preoperative levels. The DB significantly overconstrained internal rotation at different angles. Anterior translation in the lateral compartment on maximum internal rotation was significantly overconstrained using a DB. We conclude that ACL reconstruction restores near normal knee kinematics. Our data suggest that the ST-TG and the DB better control anterior translation in the lateral compartment. It also suggests that DB caries a risk of overcorrection. This study has a small sample size and should be considered as a pilot study.

Does reverse shoulder arthroplasty for tumors of the proximal humerus reduce impairment?

BACKGROUND: Normal function of the upper limb is seldom restored after limb-sparing surgery for tumors of the proximal humerus. The literature suggests superior shoulder function is achieved in the short term with reverse total shoulder arthroplasty compared to other techniques when performed for conditions with rotator cuff deficiency. It is unclear whether this superiority is maintained when reverse total shoulder arthroplasty is performed for tumors. QUESTIONS/PURPOSES: When performed for tumors, we determined whether reverse total shoulder arthroplasty restores function and improves motion, the complications associated with the surgery, and whether reverse total shoulder arthroplasty with autologous grafting is associated with bone resorption. PATIENTS AND METHODS: We retrospectively reviewed 14 patients who had undergone reverse total shoulder arthroplasty for tumors of the proximal humerus. Four patients died, leaving nine patients for review. The surviving patients were evaluated clinically and radiographically. The minimum followup was 0.6 years (mean, 7.7 years; range, 0.6-12 years). RESULTS: At last followup, mean active abduction was 157° and mean functional Constant-Murley score was 76%. One patient had a deep infection and one developed a loose prosthesis; both were treated with single-stage exchange. At last followup, both patients had reasonable function without evidence of infection or loosening. Radiographic graft resorption was seen in all but one patient. CONCLUSIONS: Our observations suggest, at medium-term followup, reverse total shoulder arthroplasty is a reasonable option for tumors of the proximal humerus. It has low morbidity, restores a mean active abduction of 157°, and limits the impairment of activities of daily living. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical and functional outcome of the Birmingham hip resurfacing.

The Birmingham hip resurfacing (BHR) arthroplasty has shown good medium-term results in the centres that have been involved in its development. A retrospective cohort study analyzing the clinical and functional outcome of 297 metal-on-metal BHR arthroplasties at an independent hospital was performed. At medium-term follow-up, 4 patients had died, 8 patients were lost to follow-up (2.7%), and 6 hips (2.0%) had undergone revision surgery. The mean Harris hip score (HHS) increased from 56.2 preoperatively to 96.4 at follow-up. The BHR resulted in a very high postoperative HHS and enabled active patients to return to work and engage in sports. With an acceptable revision rate of 2.0% and an overall survival rate of 97.1% at five years, our results were similar to those of the designer centers.

Augmentation of a patellar tendon repair with an autologous semitendinosus graft.

Patellar tendon ruptures are rare but very invalidating lesions. We describe a case of re-rupture of a sutured patellar tendon. An autologous semitendinosus graft was used for tendon augmentation in the reconstruction procedure. This technique uses an easy-to-harvest graft which has low donor site morbidity. Additionally, the strength of the graft allows early rehabilitation, and no further surgery for hardware removal is necessary. For these reasons we recommend this procedure for acute patellar tendon ruptures with a poor tissue quality or for revision surgery of the patellar tendon.