Unexpected positive cultures in patients with arthrofibrosis following total hip and total knee arthroplasty.

PURPOSE: It has been suggested that low-grade infections could be the cause of arthrofibrosis. However, this hypothesis has not been conclusively proven. The aim of this study is to assess the incidence of unexpected positive cultures (UPC) in patients undergoing revision total joint arthroplasty for a diagnosis of arthrofibrosis. METHODS: A retrospective single-centre review was performed. All patients who underwent an aseptic revision due to histologically confirmed arthrofibrosis (based on the synovial-like interface membrane (SLIM) criteria) were included. The incidence of UPC was then calculated. RESULTS: A total of 147 patients were included. Of these, 100 underwent a total knee arthroplasty (TKA) procedure and 46 a total hip arthroplasty (THA) surgery. One patient had a periprosthetic joint infection and was therefore excluded. Of the 146 included patients, 6 had confirmed UPC (4.08%). The following bacteria were identified: Anaerococcus octavius, Staphylococcus epidermidis, Enterobacter cloacae, Staphylococcus hominis, Streptococcus pluranimalium, Staphylococcus pettenkoferi. CONCLUSIONS: Our results suggest that the incidence of UPC in patients with arthrofibrosis is low. It is lower than that of UPC in patients that undergo a revision for other causes. There is no proven relationship between histologically confirmed arthrofibrosis following total joint arthroplasty and prosthetic joint infection.

A secure blood-saving protocol for Jehovah's Witnesses in primary total hip replacement.

OBJECTIVES: The study aimed to analyze the efficacy of the blood management protocol developed by our team for patients who are Jehovah's Witnesses (JW) presenting for primary total hip replacement (THR). PATIENTS AND METHODS: Thirty JW patients (6 males, 24 females; mean age: 70.1±9.8 years; range, 65 to 81 years) and 30 age- and sex-matched controls (6 males, 24 females; mean age: 68.7±9.1 years; range, 62 to 79 years) who underwent primary THR at our institution between January 2018 and June 2020 were retrospectively evaluated. While the surgical technique of THR was not different among the groups, blood loss management differed between the groups. Patients in the control group were given 1 g of intravenous tranexamic acid (TXA) 15 min before the surgical incision. In addition to the same TXA protocol, intraoperative cell salvage with a continuous autologous transfusion system was used for JW patients. The estimated blood loss (EBL) was determined using Meunier's formula. Hemoglobin (Hgb) decline, EBL on the first and third postoperative days, allogenic blood transfusion (ABT) requirement, and complications were analyzed between groups. RESULTS: There were no significant differences between groups regarding demographic and clinical characteristics (p>0.05), ABT requirement (p>0.999), and Hgb decline in the first and third postoperative days (p=0.540 and p=0.836, respectively). Furthermore, both groups did not significantly differ between EBL in the first and third postoperative days (p=0.396 and p=0.616, respectively) and the length of hospital stay (p=0.547). Similar complication rates were noted for both groups. Hemoglobin level assessments revealed that values on the first and third postoperative days were significantly lower than the baseline Hgb value in both cohorts (p<0.001). CONCLUSION: A combination of intravenous administration of 1 g of TXA, meticulous hemostasis, and intraoperative use of cell saver constitutes a reasonable strategy for achieving the goal of transfusion-free primary THR with predictable levels of blood loss that are similar to non-JW patients.

Disseminated Erysipelothrix rhusiopathiae with Secondary Prosthetic Hip Joint Infection: A Case of Successful Identification and Management in a Regional Hospital.

CASE: This article reports a case of a 72-year-old man with bilateral total hip joint replacements who suffered cuts to his hands while butchering a wild boar. He presented to the emergency department with fevers and unilateral hip pain. Erysipelothrix rhusiopathiae (E. rhusiopathiae) was isolated on hip aspirate and blood cultures. E. rhusiopathiae is a well-recognized zoonotic infection in humans, particularly in at-risk hosts, most commonly infecting swine. Infection is spread by ingestion or through skin abrasion. CONCLUSION: This illustrates an example of successful operative and perioperative management of prosthetic joint infection secondary to E. rhusiopathiae, particularly microbiological identification, within a multispecialty team of physicians and surgeons.

Three Episodes of Presumed Culture-Negative Septic Arthritis Following Intramuscular Antipsychotic Injections: A Case Report.

CASE: We present a male patient of low socioeconomic status and Maori ethnicity who experienced 3 episodes of presumed culture-negative septic arthritis of the native hip between ages 43 and 52 years. Each episode occurred within 3 weeks of intramuscular antipsychotic injection into the ipsilateral gluteal muscles. The right hip was involved in 2 presentations and the left hip in 1 presentation. No coexisting infection or underlying immune suppression was identified, and at follow-up 2 years after the last episode, he has no sequelae of septic arthritis. CONCLUSION: This report describes 3 episodes of presumed culture-negative septic arthritis after intramuscular antipsychotic injection.

Dual surgeon operating lists for complex revision arthroplasty surgery: changing orthopaedic surgical practice.

There is an increasing trend towards dual surgeon operating in complex surgeries in various specialties. This is driven by regionalisation of services, increasing complexity of surgical procedures, the ageing population and challenges imposed by changes in surgical training. Dual surgeon cases have lower complication rates and better quality of patient care. This practice not only facilitates professional and personal development, but also provides valuable support to surgeons in the early part of their career. There is a paucity of literature to support this practice, however, and prospective studies are required to demonstrate the benefit of this approach.

Defensive antibacterial coating in revision total hip arthroplasty: new concept and early experience.

BACKGROUND: Infections remains the most feared complication in total hip arthroplasty (THA). New strategies of PJI prevention includes coating of conventional implants. Defensive Antibacterial Coating (DAC), an antibacterial hydrogel coating made of hyaluronan, poly-D and L-lactide can protect biomaterials as an effective barrier at the time of implantation. In addition, it can be used with topical antibiotics to prevent early colonisation of the implant. SCOPE: This manuscript describes the detailed function of the DAC in general as well as an analysis of its use in revision THA in a series of 28 patients in a short-term follow-up.Its use in patients undergoing cementless re-implantation after 2-staged procedures in THA is described in detail within the manuscript. CONCLUSION: DAC found to be effective in terms of infection control and safety in our patient cohort and has been expanded for cementless 1-staged revisions in PJI of the hip in our institution.

Complication rates are low with the use of Stimulan calcium sulphate based antibiotic delivery system in the management of patients with hip-related PJI: early results of a consecutive case series.

BACKGROUND: Effective management of prosthetic joint infection (PJI) requires prolonged, sustained delivery of antibiotics to the effective joint space. Calcium sulphate antibiotic delivery systems have been used in this setting, however, potentially serious complications including symptomatic hypercalcaemia have been described. There is relatively little prospective data on the results with the use of these compounds. METHODS: A prospective study was performed between October 2016 and June 2018. 29 patients who underwent revision total hip arthroplasty (THA) for confirmed PJI were treated with Stimulan calcium sulphate antibiotic delivery system. Laboratory blood tests including serum calcium levels, C-reactive protein (CRP) and white cell count (WBC) were monitored for 6 weeks post-surgery. Wounds were assessed for discharge and radiographs for dissolution and for signs of heterotopic ossification. RESULTS: The mean age was 67 years and mean ASA score III. There was no significant increase between the preoperative serum calcium and those at 2 and 6 weeks. The CRP and white cell count were significantly reduced at 6 weeks. Full dissolution occurred by 6 weeks post-op. 1 patient (3.4%) had a prolonged wound discharge. CONCLUSIONS: Stimulan is a valid option for management of patients with PJI following total hip arthroplasty. Complication rates are low following its use.

Tibial alignment technique and its influence on clinical and functional outcomes following total knee arthroplasty.

BACKGROUND: Restoration of neutral mechanical axis is thought to influence implant survival and function in Total Knee Arthroplasty (TKA). There is no consensus whether Intramedullary (IM) or Extramedullary (EM) tibial alignment technique is superior to achieve this outcome. Study aims to evaluate functional and radiological outcome of TKA using the EM and IM technique. MATERIALS AND METHODS: A retrospective study of 400 primary TKA (314 patients) was performed. 200 knees were studied in each IM and EM group, which were matched. Functional assessment was performed using Oxford Knee Score (OKS) and Tibial component alignment measured in coronal and sagittal radiographs. RESULTS: The average coronal and sagittal alignment of the tibial component in IM group was 89.16° and 88°, whereas in EM group, these were 88.1° and 88.5° respectively. The adjusted mean difference change in Pre and Post-operative OKS in IM group compared to EM group was 0.5 (p = 0.52). There was no statistically significant difference in the complications between the two groups. Subgroup analysis of patients with BMI >35 showed predictable coronal tibial alignment with IM technique with fewer outliers. CONCLUSION: Intramedullary tibial alignment is associated with fewer outliers compared to the extramedullary technique particularly in patients with a BMI over 35.

Prolonged suppressive antibiotic therapy is successful in the management of prosthetic joint infection.

INTRODUCTION: Prosthetic joint infection (PJI) remains one of the major challenges facing orthopaedic surgeons. There is a paucity of evidence on non-operative management of PJI. We present the results of prolonged antibiotic suppression therapy (PSAT) in PJI from a single centre. METHODS: A retrospective study was performed. Twenty-six patients were included. Two patients were excluded due to the lack of follow-up data. Failure was defined as admission for sepsis from the joint or amputation. RESULTS: Average age was 72 years (range 35-93). Mean Charlson co-morbidity index was 4.3. Mean follow-up was 3.2 years (range 1.3-5.7). Staphylococcal species were isolated in 11 cases (44%) (MRSA 1, MSSA 5, Staph. epidermidis 4 and Staph Pasteuri 1). Other bacteria included E. Coli (2), Streptococci spp. (3), Propionebacterium acnes (1) and Pseudomonas aeruginosa (1). Four cases were polymicrobial infection (16%), and no organisms were identified in two cases (8%). Candida albicans was identified in one case. All cases of bacterial infection were treated with prolonged oral doxycycline or amoxicillin. Twenty patients (80%) received 6 weeks of intravenous antibiotics prior to commencing prolonged oral antibiotics. Two patients experienced persistent symptoms and required amputation (both TKA). Two patients experienced sepsis but were treated successfully with IV antibiotics alone. The success rate of PSAT was 84% (21/25) successful at an average 3.2-year follow-up. DISCUSSION AND CONCLUSION: Prolonged suppressive antibiotic therapy is a viable option for the management of PJI with a low incidence of complications.

Heterotopic Ossification in Orthopaedic and Trauma surgery: A Histopathological Ossification Score.

Heterotopic Ossification (HO) is a potential long-term complication in orthopaedic surgery. It is commonly classified according to the Brooker classification, which is based on radiological findings. To our knowledge the correlation of histological features to the Brooker grade is unknown as is the association between HO and the indication for revision. The aim of this paper is to analyze the ossification grade of HO tissue in patients undergoing revision hip and knee arthroplasty and to propose a histologically based classification system for HO. We also assess the relationship between the grade of HO and the indication for revision (septic and aseptic revision). From January to May 2019 we collected 50 human HO samples from hip and knee revision arthroplasty cases. These tissue samples were double-blinded and sent for histopathological diagnostic. Based on these results, we developed a classification system for the progression of HO. The grade of ossification was based on three characteristics: Grade of heterotopic ossification (Grade 1-3), presence of necrosis (N0 or N1) and the presence of osteomyelitis (HOES-Score Type 1 to 5). Demographic data as well as surgical details and indication for surgery was prospectively collected from clinical records. Fifty tissue samples were harvested from 44 hips and 6 knee joints. Of these 33 exhibited Grade I ossifications (66%), followed by 11 Grade II (22%) and one Grade III (2%). Necrosis was noted in two tissue samples (4%) and 2 more had osteomyelitis findings according to HOES-Score. Six samples (12%) with radiologically suggestive of HO turned out to be wear-induced synovitis, SLIM Type 1. Of these cases 16 were septic (32%) and 34 aseptic (68%) revisions. Most of the HO tissue samples were classified as a low-grade. High-grade ossification-Score is rare. Higher grades of ossification seem to be associated with septic revision cases. Wear-induced synovitis potentially influences HO development. A histological scoring system for ossification grading can be derived from the data presented in this study.

Cryotherapy following total knee arthroplasty: What is the evidence?

BACKGROUND: Total knee arthroplasty (TKA) is an important option in the management of severe osteoarthritis. Despite excellent long-term results following TKA, the immediate postoperative period is often associated with pain, bleeding, edema, and reduced range of movement. Cryotherapy has been shown to provide some benefit in addressing these factors but results are largely controversial. This study aims at reviewing the current existing literature on the effects of cryotherapy following TKA. METHODS: A comprehensive review of the current literature on the use of cryotherapy in knee arthroplasty was performed. The literature search was performed using PubMed, Cochrane Library, Google Scholar, and cross references using the search words "cryotherapy" AND "knee arthroplasty" for articles published between January 1990 and November 2016. RESULTS: A total of 51 articles were analyzed and 24 of them were selected based on clinical relevance. CONCLUSION: Immediate and early postoperative management following TKA remains challenging. Cryotherapy has been shown to have some benefits but the severe lack of level 1 studies supporting its use make it difficult to reach a suitable conclusion. Further multicenter randomized controlled trials with representative populations and fair comparison of devices are needed.

Do Biologic Agents Increase the Risk of Infection in Patients Undergoing Lower Limb Arthroplasty Surgery?

BACKGROUND: Biologic agents have contributed significantly to the management of patients with in rheumatoid arthritis (RA). A significant proportion of patients with RA still require arthroplasty procedures however. It is unclear whether these agents increase the risk of post operative infection after lower limb arthroplasty. METHOD: A literature search was performed for articles published over the last 10 years in the English language examining the association between anti-tumour necrosis factor inhibitors and the incidence of post operative infection in patients with RA undergoing hip and knee arthroplasty procedures. RESULTS: One large meta-analysis has been published suggesting a 2-fold increase in infection rates following orthopaedic surgery in patients receiving biological agents. When subgroup analysis of arthroplasty cases alone was performed the finding failed to reach significance. However, several further studies have demonstrated both an increased risk for surgical site infection with the use of biological agents and several conflicting articles argue the opposite. CONCLUSION: There is no current consensus on this topic. The safety of continuation of perioperative anti-TNF-α therapy in patients undergoing lower limb arthroplasty procedures is unclear. There is also little robust guidance from specialist rheumatologic societies. There is need for large scale multicentre randomised controlled trials to address this issue.

Cement-in-cement femoral component revision in the multiply revised total hip arthroplasty: results with a minimum follow-up of five years.

AIMS: We present the clinical and radiological results at a minimum follow-up of five years for patients who have undergone multiple cement-in-cement revisions of their femoral component at revision total hip arthroplasty (THA). PATIENTS AND METHODS: We reviewed the outcome on a consecutive series of 24 patients (10 men, 14 women) (51 procedures) who underwent more than one cement-in-cement revision of the same femoral component. The mean age of the patients was 67.5 years (36 to 92) at final follow-up. Function was assessed using the original Harris hip score (HHS), Oxford Hip Score (OHS) and the Merle D'Aubigné Postel score (MDP). RESULTS: The mean length of follow-up was 81.7 months (64 to 240). A total of 41 isolated acetabular revisions were performed in which stem removal facilitated access to the acetabulum, six revisions were conducted for loosening of both components and two were isolated stem revisions (each of these patients had undergone at least two revisions). There was significant improvement in the OHS (p = 0.041), HHS (p = 0.019) and MDP (p = 0.042) scores at final follow-up There were no stem revisions for aseptic loosening. Survival of the femoral component was 91.9% (95% confidence intervals (CI) 71.5 to 97.9) at five years and 91.7% (95% CI 70 to 97) at ten years (number at risk 13), with stem revision for all causes as the endpoint. CONCLUSION: Cement-in-cement revision is a viable technique for performing multiple revisions of the well cemented femoral component during revision total hip arthroplasty at a minimum of five years follow-up. Cite this article: Bone Joint J 2017;99-B:199-203.

Periprosthetic fractures associated with total knee arthroplasty: an update.

Fractures around total knee arthroplasties pose a significant surgical challenge. Most can be managed with osteosynthesis and salvage of the replacement. The techniques of fixation of these fractures and revision surgery have evolved and so has the assessment of outcome. This specialty update summarises the current evidence for the classification, methods of fixation, revision surgery and outcomes of the management of periprosthetic fractures associated with total knee arthroplasty. Cite this article: Bone Joint J 2016;98-B:1489-96.

Antibiotic prophylaxis during dental procedures in patients with in situ lower limb prosthetic joints.

The average age of patients presenting for total joint arthroplasty is decreasing. The number of primary and revision arthroplasty procedures performed in the UK, Europe and USA is increasing annually. As number of procedures performed increases, the life expectancy of our patients and therefore the in vivo duration of prosthetic joints increase, and the potential for complications such as infection increases. One potential source for this is bacterial dissemination during dental surgery. Many attempts have been made to address this issue in the form of national guidelines, but there is no clear consensus on antibiotic prophylaxis before these procedures in order to decrease the risk of prosthetic joint infection. This continues to be an area of indecision and uncertainty resulting in patients having delays in their treatment while decisions are made by oral and orthopaedic surgeons about prophylactic antibiotic use. This article reviews the existing national guidelines, highlighting the current views and issues surrounding this subject, and a critical appraisal of current evidence for the use of prophylactic antibiotics in this patient population is presented. We will also review the response in literature to the 2009 American Academy of Orthopaedic Surgeons information statement release on antibiotic prophylaxis in joint arthroplasty patients undergoing dental procedures.

Primary total hip arthroplasty with a proximally HA-coated titanium femoral component: results at 10-15-year follow-up.

INTRODUCTION: Registries in both the United Kingdom and Sweden suggest that the popularity of uncemented femoral components is increasing. As this trend progresses, long-term survival data for such components are becoming increasingly more important. We present the results of a cohort of patients treated with the Omnifit (Stryker, Mahwah, NJ) femoral component with the follow-up of 10-15 years. METHODS: A prospective study was performed in our unit between 1996 and 2001. Patients were reviewed pre-operatively and then at 6, 12, 26 and 52 weeks post-operatively and annually thereafter. They were assessed clinically and radiographically, and the Merle d'Aubigne Postel (MDP) hip score was calculated at each visit. A visual analogue scale (VAS) score and satisfaction score were also recorded to assess patient satisfaction with their procedure. Specific enquiry was made regarding anterior thigh pain. Statistical calculations were performed using the Student's t test. Kaplan-Meier survival analysis was performed. RESULTS: One hundred and four patients (113 hips) were included (48 males, 56 females). Bilateral procedures were performed in nine patients. Mean age was 60.4 years (33-72 years). Mean follow-up was 12.9 years (10-15 years). Mean pre-operative MDP score was 8.8 (3-16) and VAS score 7.8 (1-10) with ten representing the most severe symptoms. At final follow-up, the average MDP and VAS scores were 16.9 (13-18) and 2.1 (0-6), respectively. High levels of satisfaction were reported by 96.1% of patients. Two dislocations and two cases of anterior thigh pain occurred. Four patients required revision surgery. Survival of the femoral component with revision for any reason as the end point was 96%. CONCLUSION: This prosthesis provides symptom relief, return to function and high levels of patient satisfaction in the long term. Survival of this component is comparable to the best results for primary total hip arthroplasty with any means of fixation.

Primary total hip arthroplasty with hydroxyapatite coated titanium femoral stems. Does design philosophy influence long term outcome?: Results of a prospective randomised controlled trial with follow-up of 10-15 years.

We present results of a prospective randomised controlled trial examining two cohorts of patients treated with proximally (Group A) and fully coated (Group B) femoral components with long term follow up. Patients were reviewed preoperatively and 6, 12, 26 and 52 weeks post operatively then annually. The Merle d'Aubigne Postel (MDP) hip score was used to assess clinical outcome. A Visual Analog Score (VAS) was also recorded. Statistical calculation was performed using the student's t- test and Kaplan Meier survival analysis. One hundred and four patients were included in group A and 103 patients in group B. Mean age was 60.4 years and 60.8 years respectively. Mean follow- up was 12.9 years. Mean pre-operative MDP scores were 8.8 and 9.5 in Groups A and B respectively. Mean pre-operative VAS score 7.8 and 7.4 respectively. At final follow up mean MDP and VAS were 16.9, 16.6 and 2.1, 2.4 respectively. Three femoral revisions occurred in Group A. Seven revisions occurred in Group B. Survival of the femoral component with revision for any reason as the end point was 96% in Group A and 94.8% in Group B. Both components produced symptomatic relief and similar revision rates. Thigh pain occurred only in Group A.

Primary total hip replacement with a Furlong fully hydroxyapatite-coated titanium alloy femoral component: Results at a minimum follow-up of 20 years.

We present the extended follow-up (≥ 20 years) of a series of fully hydroxyapatite-coated femoral components used in 72 primary total hip replacements (THRs). Earlier results of this cohort have been previously published. All procedures were performed between 1986 and 1991. The series involved 45 women and 15 men with 12 bilateral procedures. Their mean age at the time of surgery was 60 years (46 to 80) and the mean duration of follow-up was 22.5 years (20 to 25). At final follow-up, the mean Merle d'Aubigné and Postel hip scores were 5.5 (4.5 to 6), 3.8 (3.5 to 5) and 3.3 (3.0 to 5.0) for pain, mobility and function, respectively. Of the patients 92% were very satisfied at the time of final follow-up. There were seven revisions: six of the acetabular component for aseptic loosening and one of both the stem and the acetabular component for loosening due to deep infection. The survival of this prosthesis at 22.5 years with revision for any reason as the endpoint was 91.7% (95% confidence interval (CI) 84 to 99). Survival with aseptic loosening of the stem as the endpoint was 100% (95% CI 90 to 100). This prosthesis provides pain relief in the long term. Survival of this component is comparable to the best results for primary THR with any means of fixation.