One-stage Revision With Catheter Infusion of Intraarticular Antibiotics Successfully Treats Infected THA.

BACKGROUND: Two-stage revision surgery for infected total hip arthroplasty (THA) is commonly advocated, but substantial morbidity and expense are associated with this technique. In certain cases of infected THA, treatment with one-stage revision surgery and intraarticular infusion of antibiotics may offer a reasonable alternative with the distinct advantage of providing a means of delivering the drug in high concentrations. QUESTIONS/PURPOSES: We describe a protocol for intraarticular delivery of antibiotics to the hip through an indwelling catheter combined with one-stage revision surgery and examine (1) the success as judged by eradication of infection at 1 year when treating chronically infected cemented stems; (2) success in treating late-onset acute infections in well-ingrown cementless stems; and (3) what complications were associated with this approach in a small case series. METHODS: Between January 2002 and July 2013, 30 patients (30 hips) presented to the senior author for treatment of infected THA. Of those, 21 patients (21 hips) with infected cemented THAs underwent débridement and single-stage revision to cementless total hip implants followed by catheter infusion of intraarticular antibiotics. Nine patients (nine hips) with late-onset acute infections in cementless THA had bone-ingrown implants. These patients were all more than 2 years from their original surgery and had acute symptoms of infection for 4 to 9 days. Seven had their original THA elsewhere, and two were the author's patients. All were symptom-free until the onset of their infection, and none had postoperative wound complications, fever, or prolonged pain suggestive of a more chronic process. They were treated with débridement and head and liner exchange, again followed by catheter infusion of intraarticular antibiotics. During this time period, this represented all infected THAs treated by the senior author, and all were treated with this protocol; no patient underwent two-stage exchange during this time, and no patients were lost to followup. At the time of the surgery, two Hickman catheters were placed in each hip to begin intraarticular delivery of antibiotics in the early postoperative period. Antibiotics were infused daily into the hip for 6 weeks with the tubes used for infusion only. Eleven of the single-stage revisions and four of the hips treated with débridement had methicillin-resistant Staphylococcus aureus. Patients were considered free of infection if they had no clinical signs of infection and had a normal C-reactive protein and erythrocyte sedimentation rate at 1 year. Complications were ascertained by chart review. RESULTS: Twenty of 21 (95%) infections in patients who had single-stage revision for chronically infected cemented THA were apparently free from infection and remained so at a mean followup of 63 months (range, 25-157 months). One case grew Candida albicans in the operative cultures and remained free of signs of infection after rerevision followed by infusion of fluconazole. The nine cementless THAs treated with débridement and head/liner exchange all remained free of signs of infection at a mean followup of 74 months (range, 62-121 months). Few complications were associated with the technique. Four patients had elevated serum levels of vancomycin without renal function changes and two patients had transient blood urea nitrogen/creatinine elevations with normal vancomycin levels that resolved with dosage adjustments. No patient had evidence of permanent renal damage. None of the patients in this study developed a chronic fistula or had significant drainage from the catheter site. CONCLUSIONS: Single-stage revision for chronically infected cemented THA and débridement of bone-ingrown cementless THA with late-onset acute infection followed with indwelling catheter antibiotic infusion can result in infection eradication even when resistant organisms are involved. Larger study groups would better assess this technique and prospective comparisons to more traditional one- and two-stage revision techniques for infected THA will likely require multi-institutional approaches. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Incidence and treatment of abductor deficiency during total hip arthroplasty using the posterior approach: repair with direct suture technique and gluteus maximus flap transfer.

AIMS: The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. PATIENTS AND METHODS: A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter. RESULTS: Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased. CONCLUSION: The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116-122.

Phase transformation, roughness, and microhardness of artificially aged yttria- and magnesia-stabilized zirconia femoral heads.

Yttria-stabilized zirconia ceramic (Y-TZP) has been used in total hip arthroplasty for many years but is susceptible to low-temperature aging. Medical-grade magnesia-stabilized zirconia (Mg-PSZ) is less commonly used; however, it has been shown to resist phase transformation. The purpose of this study was to directly compare the effects of artificial aging on phase transformation, surface roughness, and Vickers microhardness on Y-TZP and Mg-PSZ femoral heads. Y-TZP and Mg-PSZ heads were artificially aged in an autoclave in stages up to a total of 49 h. The surface roughness of Y-TZP significantly increased with each stage of artificial aging. Y-TZP heads aged for 49 h had a significantly higher monoclinic phase concentration and roughness, and a significantly lower microhardness, than nonaged Y-TZP heads. Artificial aging also caused the surface of Y-TZP to exhibit a lumpy "orange peel"-like appearance with a significantly higher mean peak height, suggesting that artificial aging causes individual grains to be pushed out of the surface. In contrast, artificial aging did not significantly affect the properties of Mg-PSZ heads. These findings suggest that Mg-PSZ is a satisfactory material for orthopaedic implant use, while Y-TZP, in the form tested, is not adequately stable for use as a bearing surface.

Intra-articular infusion: a direct approach to treatment of infected total knee arthroplasty.

Bactericidal levels of antibiotics are difficult to achieve in infected total joint arthroplasty when intravenous antibiotics or antibiotic-loaded cement spacers are used, but intra-articular (IA) delivery of antibiotics has been effective in several studies. This paper describes a protocol for IA delivery of antibiotics in infected knee arthroplasty, and summarises the results of a pharmacokinetic study and two clinical follow-up studies of especially difficult groups: methicillin-resistant Staphylococcus aureus and failed two-stage revision. In the pharmacokinetic study, the mean synovial vancomycin peak level was 9242 (3956 to 32 150; sd 7608 µg/mL) among the 11 patients studied. Serum trough level ranged from 4.2 to 25.2 µg/mL (mean, 12.3 µg/mL; average of 9.6% of the joint trough value), which exceeded minimal inhibitory concentration. The success rate exceeded 95% in the two clinical groups. IA delivery of antibiotics is shown to be safe and effective, and is now the first option for treatment of infected total joint arthroplasty in our institution.

Matrix Gla protein binding to hydroxyapatite is dependent on the ionic environment: calcium enhances binding affinity but phosphate and magnesium decrease affinity.

Matrix Gla protein (MGP) is an inhibitor of mineralization found in bone, cartilage, developing tissues, smooth muscle, and atherosclerotic plaques. MGP interaction with hydroxyapatite (HA) has been inferred by its function, but has never been measured directly. In this study, the influence of MGP antibody (x-MGP) binding, plasmin digestion, and various ions, including calcium and phosphate, on (125)I-labeled MGP-HA binding was examined. Nonlinear regression analysis of MGP binding yielded K(a) (association constant; approximately 8.0 x 10(4) M(-1)) and B(max) (maximum specific bound fraction of MGP; approximately 0.53). Anti-MGP antiserum reduced K(a) to less than half of control (0.33% x-MGP). Plasmin-digested MGP decreased HA binding parameters by almost a third, showing that protein binding and limited proteolysis greatly affected HA binding. The presence of free calcium ions significantly increased binding in a dose-dependent manner, with approximately 1 mmol/L calcium increasing K(a) by a factor of 2. Phosphate ions decreased binding significantly in a dose-dependent fashion, with approximately 1 mmol/L PO(4) decreasing K(a) by a third. Magnesium at approximately 1 mmol/L decreased K(a) significantly by half, but the effect was not dose-dependent. Carbonate, sulfate, and sodium ions had no significant effect on binding. MGP binding to HA is sensitive to protein binding, limited proteolysis, and the surrounding ionic environment.

Anisotropic properties of human tibial cortical bone as measured by nanoindentation.

The purpose of this study was to investigate the effects of elastic anisotropy on nanoindentation measurements in human tibial cortical bone. Nanoindentation was conducted in 12 different directions in three principal planes for both osteonic and interstitial lamellae. The experimental indentation modulus was found to vary with indentation direction and showed obvious anisotropy (one-way analysis of variance test, P < 0.0001). Because experimental indentation modulus in a specific direction is determined by all of the elastic constants of cortical bone, a complex theoretical model is required to analyze the experimental results. A recently developed analysis of indentation for the properties of anisotropic materials was used to quantitatively predict indentation modulus by using the stiffness matrix of human tibial cortical bone, which was obtained from previous ultrasound studies. After allowing for the effects of specimen preparation (dehydrated specimens in nanoindentation tests vs. moist specimens in ultrasound tests) and the structural properties of bone (different microcomponents with different mechanical properties), there were no statistically significant differences between the corrected experimental indentation modulus (Mexp) values and corresponding predicted indentation modulus (Mpre) values (two-tailed unpaired t-test, P > 0.5). The variation of Mpre values was found to exhibit the same trends as the corrected Mexp data. These results show that the effects of anisotropy on nanoindentation measurements can be quantitatively evaluated.

Primary diffuse tracheobronchial amyloidosis in a dog.

Primary diffuse tracheobronchial amyloidosis was diagnosed at necropsy in an intact male Akita dog aged 11 years, a non-productive chronic cough having been the only related clinical sign. Histologically, eosinophilic hyalinized deposits were found as a band in the lamina propria underneath the epithelium of the trachea and bronchi. When stained with Congo red, apple-green birefringence was observed in the deposits viewed with polarized light. The amyloid did not lose sensitivity to Congo red staining after incubation with potassium permanganate, indicating that it was of the AL (amyloid light chain) type. Ultrastructural features of the amyloid included a typical fibrillar meshwork with individual fibrils measuring 9.5 to 10.5 nm in diameter. This is the first report of primary diffuse tracheobronchial amyloidosis in the dog.

Size and myosin heavy chain profiles of rat hindlimb extensor muscle fibers after 2 weeks at 2G.

METHOD: The effects of 14 d of continuous centrifugation at approximately 2G on the hindlimb extensor musculature of male rats were studied. RESULTS: The mean body mass of centrifuged rats was 17% smaller than age-matched controls. In centrifuged rats, the mean absolute masses of the soleus and medial gastrocnemius (MG) were similar to control, while the mean relative masses (expressed as milligram muscle mass/gram of body mass) were larger than control. Based on a battery of monoclonal antibodies for specific myosin heavy chains (MHC), the soleus of centrifuged rats had a lower percentage (68 vs. 74%) of fibers expressing type I MHC only and a higher percentage (15 vs. 10%) that co-expressed type I and IIa MHC's. The MHC composition of fibers from the deep portion of the MG was unaffected by centrifugation. The MHC compositions based on SDS-PAGE gel electrophoresis for each muscle were similar in the two groups. Mean fiber size of each fiber type in the soleus was unaffected by centrifugation. In the MG, the fibers, expressing only type IIb MHC were smaller in the centrifuge compared to control rats. CONCLUSION: Although 2 weeks of chronic centrifugation at 2G resulted in a cessation of body growth, there was essentially no effect on the muscle masses or fiber size in either a slow or fast extensor muscle. These data suggest that periods of centrifugation may be beneficial in maintaining extensor muscle mass in an animal that is not growing at a normal rate e.g., during chronic unloading.

Diamond-like carbon coatings enhance the hardness and resilience of bearing surfaces for use in joint arthroplasty.

The purpose of this study was to evaluate the potential of a hard diamond-like carbon (DLC) coating to enhance the hardness and resilience of a bearing surface in joint replacement. The greater hardness of a magnesium-stabilized zirconium (Mg-PSZ) substrate was expected to provide a harder coating-substrate composite microhardness than the cobalt-chromium alloy (CoCr) also used in arthroplasty. Three femoral heads of each type (CoCr, Mg-PSZ, DLC-CoCr and DLC-Mg-PSZ) were examined. Baseline (non-coated) and composite coating/substrate hardness was measured by Vickers microhardness tests, while nanoindentation tests measured the hardness and elastic modulus of the DLC coating independent of the Mg-PSZ and CoCr substrates. Non-coated Mg-PSZ heads were considerably harder than non-coated CoCr heads, while DLC coating greatly increased the microhardness of the CoCr and Mg-PSZ substrates. On the nanoscale the non-coated heads were much harder than on the microscale, with CoCr exhibiting twice as much plastic deformation as Mg-PSZ. The mechanical properties of the DLC coatings were not significantly different for both the CoCr and Mg-PSZ substrates, producing similar moduli of resilience and plastic resistance ratios. DLC coatings greatly increased hardness on both the micro and nano levels and significantly improved resilience and resistance to plastic deformation compared with non-coated heads. Because Mg-PSZ allows less plastic deformation than CoCr and provides a greater composite microhardness, DLC-Mg-PSZ will likely be more durable for use as a bearing surface in vivo.

Profiles and correlates of aggressive behaviour among adults with intellectual disabilities.

BACKGROUND: Despite the heterogeneity in aggressive behaviours observed among individuals with intellectual disabilities (ID), little attention has been paid to the identification of typologies of aggression among individuals with mild or moderate ID and their associated factors. OBJECTIVE: The goal of the present study was to identify profiles of aggressive behaviour and their psychosocial correlates. METHOD: In this cross-sectional study of 296 adults with mild or moderate ID, information was gathered through interviews with the ID participants, their case manager and a significant other. Client files were also reviewed. RESULTS: Multiple correspondence analysis followed by hierarchical cluster analysis generated six distinct profiles of aggressive behaviour in this sample. The 'violent' group clearly stood out as lacking social and vocational involvement, having more severe mental health problems, high levels of impulsivity and antisocial tendencies compared with all other groups. DISCUSSION: The identification of distinct profiles of aggressive behaviour offers new possibilities for studying risk factors and eventually targeting specific risk prevention strategies.

Prevalence and types of aggressive behaviour among adults with intellectual disabilities.

BACKGROUND: Aggressive behaviours represent major obstacles to the integration into society of individuals with intellectual disability (ID) and pose significant management issues for carers. METHODS: The present study assessed the prevalence and severity of five types of aggressive behaviours in 3165 adult men and women with ID receiving services from three rehabilitation agencies in Québec by surveying their carers using the Modified Overt Aggressive Scale. RESULTS: The 12-month prevalence of aggressive behaviour was 51.8%: 24% property damage, 37.6% verbal, 24.4% self-oriented and 24.4% physical aggression, and 9.8% sexually aggressive behaviour, most of which being mild in severity. Only 4.9% of individuals displayed aggressive behaviour leading to injury of the victim. Few gender differences were observed. CONCLUSIONS: The capacity to document and assess the types as well as the severity of aggressive behaviour is thus critical, not only to better understand the correlates of various types of behaviours but also to orient intervention programmes whether they be prevention, assessment, monitoring or management of aggressive behaviour.

Elastic properties of microstructural components of human bone tissue as measured by nanoindentation.

The elastic properties of several microstructural components of dry human vertebrae (T-12 and L-1) and tibiae have been investigated in the longitudinal and transverse directions using nanoindentation. The largest Young's modulus was that for the interstitial lamellae in the longitudinal direction (25.7 +/- 1.7 GPa). This was followed in decreasing order by osteons in the longitudinal direction (22.4 +/- 1.2 GPa), trabeculae in the longitudinal direction (19.4 +/- 2.3 GPa), an average over osteons and interstitial lamellae in the transverse direction [16.6 +/- 1.1 GPa (it was difficult to microstructurally distinguish osteons from interstitial lamellae in the transverse direction)], and trabeculae in the transverse direction (15.0 +/- 2.5 GPa). An ANOVA statistical analysis revealed that the values all are significantly different (p < 0.05). Since the elastic moduli in the longitudinal direction are all greater than in the transverse, measurable elastic anisotropies exist in the components. The hardnesses also varied among the microstructural components in the range 0.52-0.74 GPa.

The distribution of osteocalcin, degree of mineralization, and mechanical properties along the length of Cyprinus carpio rib bone.

This study examined the spatial distribution of selected biochemical and mechanical properties along the length of carp rib bone. Carp rib bone was chosen because of its unusually high osteocalcin content relative to other extractable proteins. The amount of osteocalcin was significantly lower (p<0.01) at the most distal section, relative to all other sections. The amount of phosphate (p<0.05) and the elastic modulus in the longitudinal plane (p<0.0001) were found to be significantly higher in the most distal section, relative to the most proximal section. There was no significant difference in the calcium distribution, molar Ca/P ratio, or elastic modulus in the transverse plane. It was speculated that the distal section contains less mature bone. The methods illustrate the potential usefulness of nanoindentation to characterize the mechanical properties of bone, relative to its biochemical composition.

Correlations between osteocalcin content, degree of mineralization, and mechanical properties of C. carpio rib bone.

Osteocalcin is one of the most abundant noncollagenous proteins in bone. It is strongly associated with the mineral phase of bone, and has long been associated as a marker of bone turnover. However, its relationship to bone composition, strength, and structure is unclear. Carp rib bone is an excellent model for the study, because osteocalcin represents almost 60% of the total extractable noncollagenous proteins found in it. Because of the abundance of osteocalcin relative to other extractable proteins, any changes in the properties of carp rib bone would be more likely influenced by the osteocalcin concentration. To test the hypotheses that the concentration of osteocalcin is reflected in other properties of bone, the correlations between the osteocalcin concentration and the mineral content, microstructural properties, and physical characteristics of the bone mineral crystals were determined utilizing radioimmunoassay (RIA), spectrophotometry, nanoindentation, and small-angle X-ray scattering (SAXS) techniques, respectively. Osteocalcin concentration was found to be correlated to the molar Ca/P ratio and inversely correlated to the elastic modulus and hardness in the longitudinal plane. This study provides evidence for a putative relationship between the concentration of osteocalcin and the microstructural mechanical properties of bone. Correlations were also found between the mechanical properties in the longitudinal plane and both the phosphate content and the molar Ca/P ratio. However, no relationships could be identified between osteocalcin concentration and several parameters of bone crystals, as determined by SAXS.

Mechanical and morphological variation of the human lumbar vertebral cortical and trabecular bone.

The nanoindentation technique was used to characterize the variation in the elastic modulus and hardness of human lumbar vertebral cortical and trabecular bone. The elastic modulus (and in most cases, the hardness as well) of axially aligned trabeculae cut in the transverse direction was significantly greater than in other orientations of vertebral cortical and trabecular bone. In all cases, the elastic modulus and hardness of bone in the load-bearing direction was greater than in corresponding bone types cut in the other directions. Scanning electron micrographs of cortical shell revealed the Haversian-like canal systems expected in secondary cortical bone, but it was difficult to differentiate by morphology cortical from trabecular bone in the human lumbar vertebrae.