Cytotoxic Effects of Common Irrigation Solutions on Chondrosarcoma and Giant Cell Tumors of Bone.

BACKGROUND: Irrigation is commonly used as an adjuvant treatment during the intralesional curettage of bone tumors. The goal of the present study was to analyze the in vitro cytotoxicity of commonly used irrigation solutions on chondrosarcoma and giant cell tumor (GCT) cells as there is no consensus on which solution leads to the greatest amount of cell death. METHODS: An in vitro evaluation was performed by exposing human GCT and human chondrosarcoma cell lines to 0.9% saline solution, sterile water, 70% ethanol, 3% hydrogen peroxide, 0.05% chlorhexidine gluconate (CHG), and 0.3% povidone iodine solutions independently for 2 and 5 minutes. A low-cytotoxicity control (LCC) and a high-cytotoxicity control (HCC) were established to determine the mean cytotoxicity of each solution and each solution's superiority to LCC and non-inferiority to HCC. RESULTS: The present study demonstrated that 0.05% CHG was non-inferior to the HCC when chondrosarcoma was exposed for 5 minutes and when GCT was exposed for 2 and 5 minutes (mean cytotoxicity, 99% to 102%) (p < 0.003 for all). Sterile water was superior to the LCC when chondrosarcoma was exposed for 5 minutes and when GCT was exposed for 2 minutes (mean, 28% to 37%) (p < 0.05). Sterile water (mean, 18% to 38%) (p < 0.012) and 3% hydrogen peroxide (mean, 7% to 16%) (p < 0.001) were both inferior to the HCC. The 3 other solutions were non-superior to the LCC (mean, -24% to -5%) (p < 0.023). CONCLUSIONS: In vitro irrigation in 0.05% CHG provided high cytotoxicity, comparable with the HCC. Therefore, the use of a 0.05% CHG solution clinically could serve as a potential chemical adjuvant during intralesional curettage of chondrosarcoma and GCT. CLINICAL RELEVANCE: In an effort to reduce the burden of residual tumor cells, irrigation solutions are often utilized as adjuvant local therapy. Use of a 0.05% CHG solution clinically could serve as a potential chemical adjuvant to intralesional curettage of chondrosarcoma and GCT. Further in vivo studies may be indicated to assess clinical outcomes and safety associated with the use of 0.05% CHG in the treatment of chondrosarcoma and GCT.

The Use of Megaprostheses in Nononcologic Lower-Extremity Total Joint Arthroplasty: A Critical Analysis Review.

¼: As the number of primary total joint arthroplasty (TJA) procedures continues to rise, megaprostheses have found an emerging role in more complex revision arthroplasty cases that require additional reconstruction, stability, and restoration of function. ¼: Megaprosthesis options have evolved: in addition to cemented prostheses, cementless and even hybrid fixation designs optimize longevity. Proximal femoral replacement (PFR), distal femoral replacement (DFR), proximal tibial replacement (PTR), and total femoral replacement (TFR) are all limb salvage options in the setting of substantial bone loss, poor bone quality, and soft-tissue compromise. ¼: Dislocation is one of the most common complications after PFR, likely due to the loss of soft-tissue integrity, most notably the hip abductor musculature from the greater trochanter. The utilization of dual-mobility constructs, larger femoral heads, elevated acetabular liners, and constrained acetabular liners may reduce the risk of instability and improve overall hip function. ¼: Patients with megaprostheses may be more prone to periprosthetic joint infection and surgical site infection given multiple variables, such as the lengthy nature of the surgical procedure, prolonged wound exposure, extensive soft-tissue dissection and resection, poor soft-tissue coverage, and poorer host status. ¼: Despite advances in technology, complication and revision rates remain high after megaprosthesis reconstruction. Therefore, thorough attention to patient-specific factors must be considered for appropriate use of these constructs.

Paradoxical Behavior of Plasma d-Dimer From Explantation to Reimplantation in a Two-Stage Revision for Periprosthetic Joint Infection.

BACKGROUND: The variation of plasma d-dimer, an inflammatory marker, from pre-explantation to pre-reimplantation in two-stage revision remains unclear. Our objective was to evaluate delta-changes (Δ) in d-dimer, erythrocyte sedimentation rate (ESR), and C-reactive-protein (CRP), to ascertain whether these delta-changes are associated with the outcome of reimplantation. We hypothesized a decrease in d-dimer before reimplantation. METHODS: A retrospective review was performed on a consecutive series of 95 two-stage revisions indicated for periprosthetic joint infection. Surgeries were performed by 3 surgeons at a single institution (2018-2020). The minimum follow-up was 1 year. The inclusion criteria comprised availability of d-dimer results at pre-explantation and pre-reimplantation. As a result, only 30 reimplantations were included. Success of reimplantation was defined by Musculoskeletal Infection Society outcome reporting tool: Tier 1/Tier 2 vs Tier 3/Tier 4. Nonparametric tests and Mann-Whitney U-tests were conducted to compare Δd-dimer% (pre-explantation value - pre-reimplantation value/pre-explantation value × 100). The bootstrapped receiver operating characteristic curve analyses with 2,000 replicates of 30 cases were conducted. RESULTS: The median time between explantation and reimplantation was 86 days (interquartile range [IQR] = 77.7-138.5 days). Overall, a paradoxical median percent increase (Δd-Dimer% [INCREMENT] = 12.6%) in d-dimer was found from pre-explantation to pre-reimplantation (IQR = -28.06% to 77.3%). However, there was a percentage decrease in ESR (ΔESR% [DECREMENT] = -40%; IQR = -70.52% to 3.85%) and CRP (ΔCRP% [DECREMENT] = -75%; IQR = -87.43% to -61.34%). The changes in all these markers were not different between Musculoskeletal Infection Society Tier 1/2 and 3/4 outcomes (Δd-Dimer%, P = .146; ΔESR%, P = .946; ΔCRP%, P = .463). With area under curve of 0.676, Δd-dimer% (INCREMENT) appeared to be performing best in diagnosing infection control, which was nonexplanatory. CONCLUSION: Plasma d-dimer paradoxically increases before reimplantation while other inflammatory markers (ESR/CRP) decrease, emphasizing that surgeons shall adopt caution using d-dimer to make clinical decisions.

Robotic-Assisted Pelvic Reconstruction After Metastatic Renal Cell Carcinoma Resection: A Case Report.

CASE: A 76-year-old man presented with metastatic renal cell carcinoma (RCC) in the right acetabulum with pelvic compromise. The patient had right hip pain and difficulty with ambulation, as such he elected to undergo tumor resection with subsequent reconstruction of pelvic defect. Given the size and location of the anticipated pelvic defect, robotic-assisted hip arthroplasty was used to execute prosthetic component placement and anatomic pelvic reconstruction. CONCLUSION: Advances in technology, such as robotics and 3D navigation, have application in orthopaedic oncology surgery, especially for reconstructions after pelvic resections. The goal of this case report is to describe the utility of this technology in a case of metastatic RCC.

Transfusion Rates in Total Hip Arthroplasty Are lower in Patients with Direct Anterior Approach.

BACKGROUND: Blood conservation and reduction in the need for allogeneic blood transfusion (ABT) has been a subject of importance in total hip arthroplasty. There are a number of well-recognized parameters that influence blood loss during total hip arthroplasty (THA). The role of surgical approach on blood loss and the rate of ABT during THA is not well studied. The hypothesis of this study was that blood loss and the need for ABT is lower with direct anterior (DA) approach. METHODS: In a case-control retrospective cohort study, we analyzed 1,524 primary THAs performed at a single institution by seven fellowship-trained surgeons between January 2015 to March 2017. All patients received THA using either the modified direct lateral (DL) or direct anterior (DA) approach using a standard operating table. The overall ABT rate was 10.2% (155/1,524) in the cohort. Demographic, surgical, and postoperative data were extracted and analyzed. Logistic regression was used to identify independent risk factors for transfusion. RESULTS: Higher preoperative hemoglobin (p<0.001), use of DA approach (p<0.016) and administration of tranexamic acid TXA, (p=0.024) were identified as independent factors which reduced the odds of ABT. Operative time (p<0.001) was associated with an increased odd of ABT, while age, BMI and type of anesthesia were not statistically significant. CONCLUSION: Based on the findings of this study, direct anterior approach for THA appears to be protective against blood loss and reduced ABT rate, when controlling for confounding variables.

Perfil epidemiológico de los pacientes adultos mayores de 65 años con fractura de cadera. Estudio de Cohorte Transversal / Epidemiological profile of adult patients older than 65 years with hip fracture. Cross-sectional study

Introducción Las fracturas de cadera reportan una incidencia en aumento; representan un reto para la salud publica por el alto costo socioeconómico y elevada morbimortalidad. Es importante documentar las complicaciones en la población de Colombia, así como los motivos de reingreso para poder plantear estrategias que contribuyan a disminuirlas. Materiales & Métodos Se realizó un estudio descriptivo, de cohorte transversal, entre enero 2015 y diciembre 2017. Se incluyeron todos los pacientes con fractura de cadera mayores de 65 años. Se excluyeron aquellos con fracturas patológicas y pacientes con antecedente de fractura en esa cadera. Se recolectaron las variables de edad, sexo, antecedentes patológicos, uso de anticoagulantes, manejo farmacológico para osteoporosis, tipo de fractura, complicaciones intraquirúrgicas y postoperatorias, así como el tiempo total desde la fractura hasta el manejo quirúrgico. Resultados Se incluyeron 155 fracturas de cadera con edad promedio de 81.6 años. 74.8% mujeres. El subtipo de fractura más frecuente fue la intertrocantérea (46.5%). El 93.6% de los casos recibió manejo quirúrgico, siendo la artroplastia el procedimiento más realizado. Se realizó manejo quirúrgico en el 85.16% de los pacientes antes de 48 horas y al 40% antes de las 24 horas desde el momento de la fractura. El reingreso fue 20% y la principal causa fueron nuevas fracturas (5.8%). Discusión Se considera el abordaje de los pacientes desde un punto multidisciplinario que maneje sus comorbilidades, fragilidad ósea, debilidad muscular y alteraciones en la esfera mental de forma integral, ya que esto puede afectar positivamente el estado de salud de estos pacientes.

Background Hip fractures are a pathology with an increasing incidence, represent a challenge for public health due to the high socioeconomic cost and high morbidity and mortality. It is important to document the complications in our population, as well as the reasons for readmission to be able to propose strategies that contribute to reducing them. Method A descriptive, cross-sectional, retrospective study was conducted in the period between January 2015 and December 2017. All patients with hip fractures older than 65 years were included. Those with pathological fractures and patients with a history of fracture in that hip were excluded. The variables of age, sex, pathological antecedents, use of anticoagulants, type of fracture, intra-surgical and postoperative complications and total time from fracture to surgical management were collected. Results 155 hip fractures were properly documented, mean age 81.6 years, 74.8% were women. The most frequent fracture was the intertrochanteric (46.5%). 93.6% of the cases received surgical management, being hip arthroplasty the most performed procedure. Surgical management was performed in 85.16% of patients before 48h and 40% before 24h from the time of fracture. The readmission rate was 20% and the main cause was new fractures 5.8% Discussion We consider the approach of patients from a multidisciplinary standpoint that treat the comorbidities, bone fragility, muscle weakness and alterations in the mental sphere, because that may possibly affect the outcome of patients in a positive way.

Extra-Articular Hip Resection and Reconstruction with Custom Acetabular Resection Guide and Implants in a Case of High-Grade Spindle Cell Sarcoma of the Proximal Femur: A Case Report.

CASE: A 29-year-old man was admitted with acute atraumatic left hip pain and inability to bear weight. Subsequent workup revealed an intracapsular pathologic fracture of the femoral neck secondary to a high-grade spindle cell sarcoma. A unique method of extra-articular resection and reconstruction using a 3-dimensional (3D)-printed custom cutting jig and a custom acetabular component was pursued. Wide margins were achieved without violating the joint capsule but preserving pelvic integrity, allowing a return to an active lifestyle. CONCLUSION: Three-dimensional-printed custom resection guides and implants can help achieve adequate resection margins while preserving pelvic integrity and function.

Periprosthetic Joint Infection in Patients Who Have Multiple Prostheses in Place: What Should Be Done with the Silent Prosthetic Joints.

BACKGROUND: Although periprosthetic joint infection (PJI) can affect multiple joints concurrently, the majority of patients with multiple prosthetic joints present with PJI of a single joint. Data regarding the optimal management of these patients are limited. We aimed to identify the prevalence, risk factors for a subsequent PJI, and clinical circumstances of PJI in patients with multiple prosthetic joints. METHODS: We retrospectively reviewed the clinical records of 197 patients with ≥2 total joint prostheses in place who presented with PJI from 2000 to 2017. The average follow-up was 3.6 years (range, 0.5 to 17 years). Demographic data and risk factors for synchronous or metachronous PJI were identified. The time from the initial to the second PJI and organism profile data were collected as well. The workup for other joints with a prosthesis in place at the time of the initial PJI was noted. RESULTS: Among the 197 patients with PJI and multiple joint prostheses in situ, 37 (19%) developed PJI in another joint; 11 had a synchronous PJI and 26 had a metachronous PJI. The average time between the first and the second infection in the metachronous cases was 848 days (range, 20 to 3,656 days). Females and patients with an initial PJI with methicillin-resistant Staphylococcus aureus (MRSA) were more likely to have a metachronous PJI, and patients with rheumatoid arthritis had an increased risk of a second (metachronous or synchronous) PJI. Three of 11 patients in the synchronous group and 19% (5) of the 26 in the metachronous group had bacteremia at the time of the initial PJI compared with 12% (19) of the 160 with a single PJI. The percentage of negative cultures increased from 10% for the initial PJIs to 38% for the metachronous PJIs. CONCLUSIONS: Patients who have multiple prosthetic joints in place and present with PJI of a single joint are at risk of developing PJI in another joint. Female sex, rheumatoid arthritis, bacteremia at presentation, and infection with MRSA appear to be risk factors for PJI of another joint. Clinical evaluation of the other prosthetic joint(s) should be carried out in all patients and aspiration of those joint(s) should be considered for patients with any of the above risk factors. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern.

BACKGROUND: Acetabular fractures often require surgical intervention for fracture fixation and can result in premature osteoarthritis of the hip joint. This study hypothesized that total hip arthroplasty (THA) in patients with a prior acetabular fracture who had undergone open reduction and internal fixation (ORIF) is associated with a higher rate of subsequent periprosthetic joint infection (PJI). METHODS: About 72 patients with a history of acetabular fracture that required ORIF, undergoing conversion THA between 2000 and 2017 at our institution, were matched based on age, gender, body mass index, Charlson comorbidity index, and date of surgery in a 1:3 ratio with 215 patients receiving primary THA. The mean follow-up for the conversion THA cohort was 2.9 years (range, 1-12.15) and 3.06 years (range, 1-12.96) for the primary THA. RESULTS: Patients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, PJI rate was significantly higher in acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups. CONCLUSION: The present study demonstrates that conversion THA in patients with prior ORIF of acetabular fractures is associated with higher complication rate, in particular PJI, and less optimal outcome compared with patients undergoing primary THA. The latter findings compel us to seek and implement specific strategies that aim to reduce the risk of subsequent PJI in these patients.

The treatment of periprosthetic joint infection: safety and efficacy of two stage versus one stage exchange arthroplasty.

Introduction: Periprosthetic joint infection (PJI) remains one of the most dreaded and challenging complications in adult reconstruction. While primary total joint arthroplasty is one of the most successful surgeries in medicine, revisions secondary to infections do not hold as well. As the number of primary procedures increases, so will infections. In North America, two-stage exchange arthroplasty is the standard of care for patients with PJI, especially when the presentation is greater than 4 weeks after the index procedure. However, it is not necessarily the best option for all patients, particularly when compared to one-stage arthroplasty.Areas covered: The aim of this review is to analyze the indications, safety, and efficacy of two-stage exchange arthroplasty for the treatment of PJI and to compare the results reported 10 years ago with the ones of recent publications and those of one-stage arthroplasty.Expert opinion: Two-stage exchange arthroplasty is a safe and efficacious treatment particularly suited for recalcitrant infections, resistant organisms, and patients with certain host factors that make it more difficult to eradicate infection. However, one-stage arthroplasty might be well suited as well for infections caused by susceptible organisms and patients with minimal or no comorbidities or those unable to undergo two surgeries.

Polymyxin and Bacitracin in the Irrigation Solution Provide No Benefit for Bacterial Killing in Vitro.

BACKGROUND: Many surgeons add topical antibiotics to irrigation solutions assuming that this has a local effect and eliminates bacteria. However, prior studies have suggested that the addition of antibiotics to irrigation solution confers little benefit, adds cost, may potentiate anaphylactic reactions, and may contribute to antimicrobial resistance. We sought to compare the antimicrobial efficacy and cytotoxicity of an irrigation solution containing polymyxin-bacitracin with other commonly used irrigation solutions. METHODS: Staphylococcus aureus and Escherichia coli were exposed to irrigation solutions containing topical antibiotics (500,000-U/L polymyxin and 50,000-U/L bacitracin; 1-g/L vancomycin; or 80-mg/L gentamicin), as well as commonly used irrigation solutions (saline solution 0.9%; povidone-iodine 0.3%; chlorhexidine 0.05%; Castile soap 0.45%; and sodium hypochlorite 0.125%). Following 1 and 3 minutes of exposure, surviving bacteria were manually counted. Failure to eradicate all bacteria in any of the 3 replicates was considered not effective for that respective solution. Cytotoxicity analysis in human fibroblasts, osteoblasts, and chondrocytes exposed to the irrigation solutions was performed by visualization of cell structure and was quantified by lactate dehydrogenase (LDH) activity. Efficacy and cytotoxicity were assessed in triplicate experiments, with generalized linear mixed models. RESULTS: Polymyxin-bacitracin, saline solution, and Castile soap at both exposure times were not effective at eradicating S. aureus or E. coli. In contrast, povidone-iodine, chlorhexidine, and sodium hypochlorite irrigation were effective against both S. aureus and E. coli (p < 0.001). Vancomycin irrigation was effective against S. aureus but not against E. coli, whereas gentamicin irrigation showed partial efficacy against E. coli but none against S. aureus. Within fibroblasts, the greatest cytotoxicity was seen with chlorhexidine (mean [and standard error], 49.38% ± 0.80%; p < 0.0001), followed by Castile soap (33.57% ± 2.17%; p < 0.0001) and polymyxin-bacitracin (8.90% ± 1.40%). Povidone-iodine showed the least cytotoxicity of the efficacious solutions (5.00% ± 0.86%). Similar trends were seen at both exposure times and across fibroblasts, osteoblasts, and chondrocytes. CONCLUSIONS: Irrigation with polymyxin-bacitracin was ineffective at bacterial eradication, and statistically inferior to povidone-iodine. Chlorhexidine lavage conferred the greatest in vitro cytotoxicity. CLINICAL RELEVANCE: These data suggest that the addition of polymyxin-bacitracin to saline solution irrigation has little value. Given the cost and antimicrobial resistance implications, our findings, combined with prior clinical literature, provide adequate reason to avoid widespread use of antibiotics in irrigation solutions. Povidone-iodine may be a more effective and safer option.

Outcomes of Superficial and Deep Irrigation and Debridement in Total Hip and Knee Arthroplasty.

BACKGROUND: Following total knee arthroplasty and total hip arthroplasty, wound-related problems and deep periprosthetic joint infection may present in a similar fashion. Irrigation and debridement (I&D) has a great role in management of patients with early infection. The question that often arises is how to tell the difference between superficial and deep infection. This study evaluated the role and outcomes of both superficial and deep I&D in patients with wound-related issues and/or suspected periprosthetic joint infection. METHODS: A retrospective study was conducted evaluating patients who underwent I&D within 28 days of total joint arthroplasty. A total of 176 cases with a minimum of 1-year follow-up were identified, and clinical records were reviewed in detail. Reoperations included superficial (fascia not opened) or deep (fascia opened) I&D. Failure was defined as the need for further surgical intervention within 1 year of initial I&D. RESULTS: The overall success for superficial I&D was 84.28% vs 68.86% for deep I&D. The success of both deep and superficial I&D was higher if the I&D was performed closer to the index surgery. Superficial I&D in patients with a positive joint aspiration or evidence of intraoperative purulence or those in whom had no subcutaneous fluid had higher failure rates. CONCLUSION: Superficial I&D is a viable option in patients with wound-related issues as long as joint aspiration is performed to rule out infection involving the prosthesis. If there are findings of no fluid or purulence, fascia may need to be opened and the deeper tissues explored.