Aim

This study assessed quality of life (QoL) in patients having external fixation for treatment of osteomyelitis and fracture-related infection (OM/FRI).

Background

Data regarding the diagnostic value of ultrasound (US)-determined fluid film and joint aspiration prior to revision total hip arthroplasty (THA) for suspected periprosthetic joint infections (PJIs) is limited. This study aimed to analyse (1) the value of US-determined fluid film, (2) characterisation of the pre- and intraoperative microbiological spectrum and resistance patterns and (3) the concordance between preoperative synovial fluid and intraoperative culture results.

Aim

To investigate the impact of waiting for surgical treatment for bone and joint infection (BJI) on patient self-reported quality of life (QoL).

Aims

The aim of this study was to assess the incidence the microbiological spectrum and clinical outcome of hip and knee revision arthroplasties with unexpected-positive-intraoperative-cultures (UPIC) at a single center with minimum follow up of 2 years.

Aim

Pin site infection (PSI) is a common complication of external fixators. PSI usually presents as a superficial infection which is treated conservatively. This study investigated those rare cases of PSI requiring surgery due to persistent osteomyelitis (OM), after pin removal.

Aim

Synovial calprotectin point-of-care test (POC) has shown promising clinical value in diagnosing periprosthetic joint infections (PJIs). However, limited data are available in unclear cases. Moreover, cut-off values for calprotectin lateral flow assay (LFA) and enzyme-linked immunosorbent assay (ELISA) need to be adapted. The aim of this study was to evaluate the performance of an upgraded and more sensitive version of a synovial calprotectin LFA along with ELISA immunoassay in patients with septic, aseptic, and unclear cases.

Aim

Culture-based conventional methods are still the gold standard to identify microorganisms in hip and knee PJIs diagnosis. However, such approach presents some limitations due to prior antimicrobial treatment or the presence of unusual and fastidious organisms. Molecular techniques, in particular specific real-time and broad-range polymerase chain reaction (PCR), are available for diagnostic use in a suspected PJI. However, limited data is available on their sensitivity and specificity.

This study aimed to evaluate the performance of a rapid and simple Investigational Use Only (IUO) version of the BioFire® JI multiplex PCR panel when compared to traditional microbiological procedures.

Aim

Analysis of microbiological spectrum and resistance patterns as well as the clinical outcome of patients who underwent a Debridement, antibiotics and implant retention (DAIR) procedure in the early phase following failed two-stage exchange arthroplasty of the knee and hip.

Purpose

Unexpected-positive-intraoperative-cultures (UPIC) in presumed aseptic revision-total-knee-arthroplasties (rTKA) are common, and the clinical significance is not entirely clear. In contrast, in some presumably septic rTKA, an identification of an underlying pathogen was not possible, so called unexpected-negative-intraoperative-cultures (UNIC). The purpose of this study was to evaluate alpha defensin (AD) levels in these patient populations.

Aim

In severe cases of postoperative spinal implant infections (PSII) multiple revision surgeries may be needed. Little is known if changes of the microbiological spectrum and antibiotic resistance pattern occur between revision surgeries. Therefore, the aim of this study was to analyze the microbiological spectrum and antibiotic resistance pattern in patients with multiple revision surgeries for the treatment of PSII. Furthermore, changes of the microbiological spectrum, distribution of mono vs. polymicrobial infections, and changes of the antimicrobial resistance profile in persistent microorganisms were evaluated.

Aim

Dalbavancin is a novel second-generation lipoglycopeptide antibiotic with strong activity against many gram-positive bacteria and a prolonged half-life of 6–11 days. This allows a once-a-week intravenous application and therefore an outpatient intravenous therapy. Currently, only little is known about the use of Dalbavancin in Periprosthetic joint infection (PJI). The aim of this retrospective study, was to compare the outcome of hip and knee periprosthetic joint infections (PJI) in patients who received dalbavancin (DAL) with patients which was treated by standard of care antimicrobial agents (SoC).

Aim

Little is known about microbiological spectrum and resistance patterns as well as the clinical outcome in patients who undergo a repeat first stage procedure as part of a 2-stage revision arthroplasty for the treatment of periprosthetic hip and knee joint infections.

Cell therapies hold significant promise for the treatment of injured or diseased musculoskeletal tissues. However, despite advances in research, there is growing concern about the increasing number of clinical centres around the world that are making unwarranted claims or are performing risky biological procedures. Such providers have been known to recommend, prescribe, or deliver so called ‘stem cell’ preparations without sufficient data to support their true content and efficacy. In this annotation, we outline the current environment of stem cell-based treatments and the strategies of marketing directly to consumers. We also outline the difficulties in the regulation of these clinics and make recommendations for best practice and the identification and reporting of illegitimate providers.

Cite this article: Bone Joint J 2020;102-B(2):148–154

A substantial body of evidence supports the use of extracorporeal shock wave therapy (ESWT) for fracture non-unions in human medicine. However, the success rate (i.e., radiographic union at six months after ESWT) is only approximately 75%. Detailed knowledge regarding the underlying mechanisms that induce bio-calcification after ESWT is limited. The aim of the present study was to analyse the biological response within mineralized tissue of a new invertebrate model organism, the zebra mussel Dreissena polymorpha, after exposure with extracorporeal shock waves (ESWs). Mussels were exposed to ESWs with positive energy density of 0.4 mJ/mm² or were sham exposed. Detection of newly calcified tissue was performed by concomitantly exposing the mussels to fluorescent markers. Two weeks later, the fluorescence signal intensity of the valves was measured. Mussels exposed to ESWs showed a statistically significantly higher mean fluorescence signal intensity within the shell zone than mussels that were sham exposed. Additional acoustic measurements revealed that the increased mean fluorescence signal intensity within the shell of those mussels that were exposed to ESWs was independent of the size and position of the focal point of the ESWs. These data demonstrate that induction of bio-calcification after ESWT may not be restricted to the region of direct energy transfer of ESWs into calcified tissue. The results of the present study are of relevance for better understanding of the molecular and cellular mechanisms that induce formation of new mineralized tissue after ESWT. Specifically, bio-calcification following ESWT may extend beyond the direct area of treatment.

Introduction

The impact of prior ipsilateral shoulder surgery on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) is unknown. The purpose of this study was to determine the impact of prior shoulder surgery on patients undergoing TSA and RSA compared to patients without prior shoulder surgery. The hypothesis was that patients undergoing arthroplasty after prior ipsilateral shoulder surgery would have inferior outcomes with higher complication rates compared to patients undergoing arthroplasty without having undergone prior surgery.

The Radiographic Union Score for Hip (RUSH) is an outcome instrument designed to describe radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining non-union in clinical trials and predicting patients that likely require additional surgery to promote fracture healing. We sought to determine a RUSH threshold score that defines nonunion at 6-months post-injury. Our secondary objective was to determine if this threshold was associated with increased risk for non-union surgery.

A sample of 248 patients with adequate six-month hip radiographs and complete two-year clinical follow-up were analysed from a multi-national hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the six-month post-injury radiographs, and agreement was assessed using the Interclass Correlation Coefficient (ICC). Fracture healing was determined by two independent methods: 1) prospectively by the treating surgeon using clinical and radiographic assessments, and 2) retrospectively by a Central Adjudication Committee using radiographs alone. Receiver Operator Curve analysis was used to define a RUSH threshold score that was specific for fracture nonunion.

RUSH score inter-rater agreement was high (ICC: 0.81, 95% CI 0.76 to 0.85). The mean six-month RUSH score for all included patients was 24.4 (SD 3.4). A threshold score of <18 was associated with a greater than 98% specificity for nonunion. Furthermore, patients with a six-month RUSH score below 18 were more the seven-times more likely to require revision surgery for nonunion (Relative Risk: 7.25, 95% CI 2.62 to 20.00).

The six-month RUSH score can effectively be used to communicate when a femoral neck fracture has not healed. The validity of our conclusions was further supported by the increased risk of nonunion surgery for patients below the RUSH threshold. We believe our findings can standardise a definition of nonunion for clinical trials and recommend the use of the RUSH and its <18-point threshold when describing femoral neck nonunion.

Background

Malposition of the glenoid component in total shoulder arthroplasty (TSA) is associated with higher strain patterns and can result in component loosening. Glenoid hardware placement and optimal size remain challenging due to the difficult joint exposure and visualization of anatomical reference landmarks during the procedure. Therefore, understanding both normal and variant patterns of glenoid anatomy is imperative for success in TSA. To better understand individual variations in glenoid morphology, this study aimed to compare the glenoid anatomy in a cohort of male and female patients from the United States (US) and Australia (AUS).

BACKGROUND

Despite many years of clinical experience the optimal bearing choice in total hip arthroplasty (THA) remains controversial. This study aims to directly compare the three widely used bearing surfaces: metal-on-highly crosslinked polyethylene (MoHXLPE), ceramic-on-ceramic (CoC) and metal-on-metal (MoM), regarding clinical and radiologic outcome parameters.

Introduction

Reverse Shoulder Arthroplasty (RSA) improves the mechanics of rotator cuff deficient shoulders. To optimize functional outcomes and minimize failures of the RSA manufacturers have recently made innovative design modifications with lateralized components. However, these innovations have their own set of biomechanical trade-offs, such as increased shear forces along the glenoid bone interface. The objective of this study was to develop an efficient musculoskeletal model to evaluate and compare both the muscle forces and joint reactive force of a normal shoulder to those implanted with varied RSA implant designs. We believe these findings will provide valuable insight into possible advantages or shortcomings of this new RSA design.

Purpose

Pain and stiffness from elbow arthritides can be reliably improved with arthroscopic osteocapsular ulnohumeral arthroplasty (OUA) in selected patients. Post-operative continuous passive motion (CPM) may be helpful in reducing hemarthrosis, improving soft-tissue compliance and maintaining the range of motion (ROM) established intra-operatively. There is only one published series of arthroscopic OUA and CPM was used in a minority of those patients. We hypothesized that a standardized surgical and post-operative CPM protocol would lead to rapid recovery and sustained improvement in ROM.

Background: Recently, the new phenomenon of “squeaking” noises emitted from THAs with ceramic-onceramic bearings has spared international interest. It shows a frequency of 0,7–19,5% in literature, but infrequently requires revision surgery. However, an even higher incidence of various other noises from those THAs audible to the human ear have become popular in the process: this noise can resemble clicking, grinding or creaking and can be caused by distinct movements, during longer periods of walking, or can be constant with movement. The incidence of those noises can reach up to 30% of THAs. However, memory has faded that other bearings like metal-on-metal and PE/ceramic have been associated with noises in the past.

Therefore we aimed to investigate the occurence of acoustic emissions in patients, who had all received the same implant but with alternate bearings, to investigate the nature of noise, duration and clinical consequence for all 3 bearings (polyethylene/ceramic, metalon-metal, ceramic-on-ceramic).

Method: Between 1999–2001, 360 patients were matched in a prospective randomised trial. All of them received a cementless Zimmer© Alloclassic Variall™ implant at the Orthopaedic Hospital Vienna – Speising, Austria with either a ceramic-on-ceramic bearing, a metal-on-metal bearing or a polyethylene/ceramic bearing. A questionnaire was sent via mail, including questions on first occurence of hip noise, information on the kind and duration of the phenomenon and possible adverse evaluation on behalf of the patient. In case of a positive report, the patient was invited to a clinical examination and radiographic analysis. In addition, a specialised audiography was conducted in patients with audible sensations. Finally, the SF-36 and WOMAC were analysed. A number of patients received further examination with methods of gait analysis in order to detect the distinct point of occurence of the noise during the gait cycle.

Results: 33 patients reported an audible phenomenon from their THA, 14 received a ceramic-onceramic bearing (Cerasul), 13 a polyethylene/ceramic bearing (Durasul) and 6 a metal-onmetal bearing (Metasul). The most common noise was a distinct clicking, followed by a creaking noise. Only 1 patient reported a squeaking sensation, he received a polyethylene/ceramic bearing.

Conclusion: The emission of specific noises from THAs of all bearings has been well documented in recent trials and could be verified in this survey of cementless THAs. No trend towards an increased incidence of noise from THAs with ceramic-on-ceramic bearings could be detected. Interestingly, the single case of „squeaking” was reported from a patient with polyethylene/ceramic bearing. Microseparation and subluxation of the femoral head with resulting edge loading and formation of stripe wear has recently been suspected as the main cause for “noisy hips.” So far 2 ceramic-on-ceramic hips of this study group population have been revised. Both articulations showed areas of stripe wear due to subluxation of the joint.

Introduction: Open fractures with severe soft tissue damage, uncovered osteosynthesis material and chronic soft tissue defect due to infection as well as its consequences represent a special challenge for the therapeutic strategy.

In these cases the soft tissue coverage has a particular importance.

Patients: Within a 24-month period (2005 to 2006) 145 open fractures of the lower leg and foot were treated. 34 of these showed a 1 °, 74 a 2 ° and 37 patients with 3 ° soft tissue damage. Furthermore, data on 16 patients with chronic soft tissue defect by infection, which had a flap coverage, have been evaluated.

Score: The average age was 43.3 years (6 to 68), the ratio of women to men 2:1. Primary definitive osteosynthesis was performed in 68 patients (47%). In 19 patients a local muscle flaps plastic (Soleus, Gastrocnemius, peroneus brevis) was carried out. Three of these were already covered in the context of the primary treatment. Fasciocutaneous flaps were performed in 17 patients.

In the most cases the defect site was closed by primary would healing, additional procedures (excision of skin necrosis, mesh grafting) were necessary in 8 cases. In one case we saw a complete loss of the muscle flap.

Conclusion: In addition to an adequate diagnosis (X-Rays, MRI) the soft tissue reconstruction of acute or chronic soft tissue defects, where the osteosynthesis material or the septic bone is uncovered, is also necessary. In the lower extremities local muscle flaps (M. soleus, M. gastrocnemius) or for smaller defects fasciocutaneous flaps (suralis) are particularly suitable.

Aim: Because of the low prevalence, there is a poor evidence on the effective management of bone and joint infections of the carpus and metacarpus. We therefore studied the outcomes of patients undergoing surgical treatment at our department.

Method: We conducted a retrospective study on all patients operated on because of osteomyelitis of the carpus and metacarpus between January 1998 and June 2004. Main study endpoint were the infection controll rate at end of treatment and at time of follow-up.

Results: Of eleven subjects (nine men, two women) with a median age of 43 years (range, 19 to 79 years) serial débridement with temporary wound closure and surgical fixation proved successful in ten cases. We identified causative pathogens in ten cases (S. aureus: n=3, P. aeruginosa: n=3, mixed: n=4) by intraoperative biopsy. Eight subjects received local or free tissue flaps. A 73 year old man died in hospital.

Follow-up information was available for eight patients after a median of 19,5 months (range: 3 to 61 months). Seven of them did not show signs of recurrent infection.

Conclusion: Adhering to accepted standards of treating osteomyelitis, satisfactory control rates in carpal and metacarpal infection can be achieved while salvaging the hand.

According to the International Classification of Psychic Disturbances (ICD 10) accidents are among the traumatic incidents in a person’s experience and can lead to acute or persisting post traumatic strain reactions. During the primary medical treatment and care the patient first of all has to come to terms with the consequences of the accident. If an acute osteomyelitis occurs later on, this will be a further strain on the patient’s convalescence. At this point in time the extent of this infection is not foreseeable, neither for the team treating the patient nor for the patient him/herself. While the accident itself is to be seen as an acute trauma, the development of a chronic infection is a creeping and uncertain process. On the one hand the patient is confronted with the psychic effect of the accident and its consequences and on the other hand with the psychic effects of drawn-out treatment.

Apart from functional restrictions and cosmetically straining outcomes the patients suffer under the social effects, such as loss of work and threats to finances, changes, or loosing a partner and the social surroundings and restrictions in leisure activities. The psychological effects of chronic strain are a depressive attitude, loosing control when acute pain occurs, a decrease in sexual needs, alcohol or medication abuse and not rarely a permanent change in personality. Added to this are worries about the future, fear that the infection can “flare-up” again or the necessity of an amputation. According to the literature the existence of chronic pain is the most serious influential factor on a patient’s quality of life.

The question which personality factors contribute to the development of chronic osteomyelitis has not been answered to date. Investigations only show a connection between patients with psychiatric illnesses and a higher liability to be ill. Klemm et al. (1988) specified that for a small group of patients psychosomatic factors are involved in the “definition” (but not the cause) of chronic osteomyelitis.

The psychological treatment deals with the results of the accident and the effect of the drawn-out treatment.

Starting point is a detailed psychological and social requirement and problem orientation with an active analysis of problems and to look for resolutions. A subjective appraisal of the illness, the psychic resilience, intellectual abilities, cognitive handling strategies, personal and social resources all have a decisive effect on the progress of the therapy.

Purpose: Elective total hip and knee replacement surgeries are effective procedures for patients suffering from hip and knee disease. The demand for joint replacements is expected to rise as the life expectancy of Canadians increases; thus putting a heavy burden on healthcare. In an effort to reduce the acute hospital length of stay (LOS) the Alberta Orthopaedic Society, with the Alberta Bone and Joint Health Institute, three Alberta health regions (Calgary, Capital and David Thompson) and Alberta Health and Wellness created an evidence based new care continuum for hip and knee replacement. The LOS through the new care continuum compared to the current conventional approach was evaluated. In addition patient characteristics that could potentially predict the LOS were evaluated.

Method: The study design was a randomized, controlled trial. Consenting subjects were randomized to receive care through either the new care continuum (intervention) or the existing “current conventional approach” (control). Acute hospital LOS was calculated as the difference between the date and time the patient was admitted to the date and time the patient was discharged. Data was collected on patient characteristics potentially associated with acute hospital LOS.

Results: Intervention patients demonstrated a significantly shorter acute hospital LOS than the control patients, 4.66 and 5.95 days respectively. Further analysis of the data using a generalized linear model indicated that several patient characteristics were associated with a shorter/longer wait for consultation and surgery. Married patients had a statistically significant shorter LOS than single patients (IRR=0.89, p=0.001). Whereas older patients (IRR=1.01, p=< 0.001), patients with increased comorbidity (IRR= 1.03, p=0.001), and patients with an ASA of ≥ 3 (IRR= 1.22, p=< 0.001) resulted in a significantly longer LOS.

Conclusion: This study indicated that an evidence based healthcare continuum for the delivery of hip and knee replacements was successful in significantly reducing acute care LOS. Reducing the LOS using the new care continuum could potentially help alleviate the strain on limited healthcare resources and the savings could be reinvested to increase the numbers of joint replacement performed. Furthermore, an understanding of patient characteristics that influence acute hospital care LOS should be used to model surgical case mixing to further improve efficiencies.

Purpose: Unrepairable fractures of the radial head are often treated with radial head arthroplasty. Insertion of a radial head prosthesis that is too thick, or overstuffed, is believed to be a common complication that may result in pain, arthrosis, capitellar wear and decreased elbow range of motion. The purpose of this study was to develop guidelines for determining the appropriate thickness of radial head implants. We hypothesized that

radiographic incongruity of the medial facet of the ulnohumeral joint and that

Method: Six human cadaveric upper extremities were used to evaluate the clinical and radiographic effects of overstuffing of a radial head arthroplasty. Each specimen received an anatomic radial head replacement and then underwent overstuffing with +2 mm, +4 mm, +6 mm and +8 mm lengths. Gross lateral ulnohumeral joint spaces were measured, and anteroposterior radiographs were taken of the elbow from which radiographic medial and lateral ulnohumeral joint spaces were measured.

Results: Intraoperative gapping of the lateral ulnohumeral facet was shown to be highly reliable for detecting radial head overstuffing, increasing from a mean of 0.0 mm at standard length to 1.0 mm with 2 mm overstuffing (p < 0.05). Radiographically, the congruity of the lateral ulnohumeral facet was significantly different with 2 mm of overstuffing as compared to the anatomic length (p < 0.05). The congruity of the medial ulnohumeral facet only became significantly different with +6 mm of overstuffing as compared to the anatomic length (p < 0.05).

Conclusion: Radiographic incongruity of the medial facet of the ulnohumeral joint was an unreliable indicator of radial head overstuffing. Radiographic gapping of the lateral ulnohumeral facet demonstrated sufficient sensitivity to diagnose radial head overstuffing when compare to the standard length implant radiographs. Visual gapping of the lateral ulnohumeral facet on the cadaver specimens reliably indicated radial head overstuffing and should be a useful anatomic feature to assess intraoperatively.

Purpose: Total hip and knee replacements are recognized as effective surgical interventions for severe arthritis. Increasing demand for these services has led to increasing waits for both consultation and surgery. The Alberta Orthopaedic Society, with the Alberta Bone and Joint Health Institute, the Calgary Health Region, the Capital Health Region, the David Thompson Health Region and Alberta Health and Wellness carried out an analysis and an evidence based redesign of the care continuum for hip and knee replacement surgery in an effort to reduce wait times and improve the quality of service for patients.

Method: The study design was a randomized, controlled trial. Consenting subjects were randomized to receive care through either the new care continuum or the existing “current conventional approach”.

Results: During the 12 month study, 1570 patients received surgery. The mean wait for an orthopaedic consultation for intervention patients was 106 days compared to 200 days for the control patients. The mean wait for hip or knee surgery for intervention patients was 157 days compared to 408 for the control patients. Further analysis of the data using a generalized linear model utilizing negative binomial regression indicated that several patient characteristics were associated with a shorter/longer wait times. The less the severity of the disease pre-surgery was associated with a longer wait for a consult (IRR=1.01, p=< 0.001). Longer waits for surgery were statistically associated with less disease severity (IRR=1.004, P=0.019), documented delay (due to non-arthritic medical concerns or patient request for delay, IRR=1.61, p=< 0.001), increased comorbidity (IRR=1.03, p=0.015), and smoking (IRR=1.30, p=0.020).

Conclusion: The results of this study confirm that a redesigned joint replacement new care continuum with a standardized primary care referral process to centralized, specialized joint replacement clinics without established backlogs can help reduce wait times in Canada.

The aim of this study was to characterize the effect of ligament water content on the accumulation of damage in vitro. MCLs of the rabbit knee were subjected to a constant cyclic stress for twenty-four hours (isotonic or hypotonic solution) and then failed. Ligaments cycled in hypotonic solution at 0.1 Hz demonstrated significantly more cyclic strain during loading and had significant reductions in both failure stress and failure strain. This study has demonstrated that elevated tissue water content influences the accumulation of damage in ligaments subjected to repetitive loading in vitro, leading to reductions in both strength and failure strain.

Ligament water content may be altered in vivo during activity, following injury or during surgical intervention; tissue hydration can also be manipulated during in vitro testing. Currently, the effect of ligament water content on the accumulation of damage with loading is unknown. The aim of this study was to characterize the effect of ligament water content on the accumulation of damage during in vitro mechanical testing. We hypothesized that Medial Collateral Ligaments (MCL) subjected to repetitive stress under hypotonic conditions would accumulate more damage than ligaments loaded in an isotonic environment.

MCLs of the rabbit knee were subjected to a constant cyclic stress (28 MPa) in this ex vivo model of loading. Tissues were bathed in either an isotonic or hypotonic solution (10% or 0.1% Sucrose) and were cycled at one of two frequencies (1 Hz or 0.1 Hz) for 24 hours followed by failure testing.

After twenty-four hours of loading, ligaments cycled in hypotonic solution at 0.1 Hz had statistically significant reductions in both failure stress and failure strain. This group also demonstrated significantly more cyclic strain during loading than MCLs cycled in isotonic solution. Surprisingly, a significant difference in cyclic modulus was not detected between groups.

This study has demonstrated that elevated tissue water content influences the accumulation of damage in ligaments subjected to repetitive loading in vitro, leading to reductions in both strength and failure strain. The interaction between tissue water content, cyclic strain and tissue damage will be the focus of further study.

Based on our experience with an anatomically shaped-femoral stem - helitorsion stem - and on the concept of rotatory locking, we presents our results in osteointegration and bone remodeling.

The study is documented in a prospective study of 84 consecutive helitorsion implants with 6 years 8 month follow-up with no exclusion critera relative to age, gendre, morphology of the femur, bone density, etiology. The stem: forged titanium alloy; roughness 6.5 achieved with corundum treatment; conical proximally, cylindrical distally; double curvature in the sagittal plane; in the horizontal plane, replicates the natural helix of the femurits main feature-; HA coating(200μm) over its proximal 2/3. Stem insertion: helicoidal motion along the long axis of the femur and rotation in the horizontal plane. Rotation is mandatory. The stem is pushed down until the oval shape of the stem matches the oval shape of the femur – at each metaphyseal level – over a more or less extended height depending on the femoral morpho-type; this horizontal locking prevents further downard motion.

This uncemenred helitorsion stem yelds remarkably good radiological results: there is a radiological silence. We think that is attribuable to helitorsion with ensures an even distribution of loads, and applies oblique and not perpendicular loads to the bone-implant interface

Introduction: Posttraumatic osteoarthritis of the ankle joint usually occurs secondary to an intraarticular fracture of the weight bearing ankle joint. The question whether also recurrent ankle sprain and /or chronic instability alone can cause this entity, is, however, still a question to debate. The aim of this retrospective study was, therefore, to analyse the history and findings of a consecutive series of patients that were treated for post-traumatic end-stage osteoarthrosis of the ankle.

Methods: The complete database (including physical exam, standard radiographs, patient questionnaire and AOFAS hindfoot score) of all patients was analysed.

Results: Out of 268 patients (females, 135 patients; males, 133) 221 (82.5%) had had a fracture (Fx) and 47 (17.5%) suffered from chronic ankle instability with recurrent sprains (but did not have a fracture). The latter group could be subdivided into 29 (10.8%) patients with recurrent sprains (RS) and 10 (6.7%) patients with only a single sprain (SS). The mean (range) delay between primary trauma and surgical treatment for endstage osteoarthritis was 21.1 (1–58) months for Fx, 37.07 (1–61) months for RS and 22.5 (5–48) months for SS.

Conclusion: Obviously, not only fractures, but also severe sprains and /or chronic instability play an important role as a cause of end stage osteaorthrosis of the ankle joint. The obtained results suggest that a single severe sprain (dislocation) can cause similar articular damages to an intraarticular fracture, as the time to develop osteoarthrosis does not differ. This is in contrast to the current opinion that ankle sprain, in most instances, does not result in symptomatic articular degeneration.

Introduction: Survivorship of total joint replacement is limited by infection or mechanical failure. While acute infection is obvious low grade infection is sometimes difficult to prove.

Regarding to the literature the management in revision surgery I terms of differentiate between septic and aseptic loosening is still a matter of debate.

Material and Methods: From 1997 to 2004 we investigated 228 revision total knee replacements prospectively as far as bacterial colonisation is concerned. If there was pre- or intraoperative evidence of infection the loosening was quoted as septic. So 40 two stage revision in cases of suspicion and 188 one stage revision had been performed.

Specimen of joint fluid, of membranes from the metal-cement and cement-bone interfaces were collected an together with all retrieved components they were investigated through a specific microbiological protocol. All isolated bacterias have been specified and categorised with biochemical methods.

Results: As a result of this specific protocol 65 of the primarily assessed as aseptic cases proved to be infected. As far as spectrum is concerned coagulase-negative Staphylococcus was found in the majority of the cases.

These bacteria are known to produce a film of exo-polysaccharide around implants which leads to resistance against immune competent cells as well as to antibiotics, hi all these cases pre and intraoperative screening tests were negative in regards to infection.

Conclusion: Conclusively only the characteristic medical history with a short term pain free period followed by persisting pain or discomfort is suspicious for low grade infection. Our investigation raises the question if coagulase-negative Staphylococcus is a reason for aseptic loosening in clinically bland cases and if low grade infection is more frequent than expected.

The C-arm is routinely used introperatively to control the anatomic structures during osteotomies and during reposition and nailing of the femoral neck fractures.

Fluoroscopic navigation has been introduced in spinal surgery and it is a widely accepted tool for pedicel screws. It has been proven that fluoroscopic imaging in two planes shows an adequate reproduction of the 3-dimensional anatomy and enables a realistic acquisition for computer-assisted navigation.

This experience with the Medtronic system is now adapted for application as the „Viking System“ for total knee replacement using the Genesis II knee arthroplasty.

After experimental cadaver studies and critical evaluation the system was tested the first time in our clinic during live surgery. In the first series of 40 Genesis II TKR we could establish a high degree of accuracy and reproducibility with the fluoroscopic navigation. Several advantages using the fluoroscopic navigation can be shown:

The navigation offers an online documentation at each step during surgery

During the study we could find a reduction of the time of surgery. The examination of additional laxity tests at various degrees of flexion with the trial implants in situ give an assessment of the ligament stability.

Fluoroscopic assisted navigation may be used during the routine TKR to be prepared for the difficult case and to avoid malalignment in the routine TKR.

Further investigation i. e. in a prospective study may reveal the advantage of navigation in correlation to the clinical outcome and the survival rates of the TKR.

Purpose: The difficulty of successive reconstructions of the anterior cruciate ligament (ACL) using an autologous graft depends on many factors. The choice of the new transplant is crucial. The purpose of this study was to assess outcome in 17 patients who underwent successive repairs of the ACL after failed patellar tendon graft where the same patellar ligament site was used to harvest the graft. This choice resulted from the width of the existing bone tunnels (irrespective of the type of screw used) that were often correctly positioned by contraindicated a relatively narrow transplant.

Material and method: The graft was obtained from the patellar ligament at the same site as used for the primary repair in 19 patients. The graft was medialised so half of the fibres were cicatricial and half were tendon with bone prolongations. Arthroscopy revealed a lesion of the distal portion of the transplant near the tibial inertion in nine cases, a proximal lesion in five cases and distension in five cases. Five patients had also had a contralateral plasty of the ACL. Mean age was 31 years. Symptoms included instability, alone or with pain. In 12 cases, partial meniscectomy was performed before or during the repeat plasty procedure. Minimum follow-up was one year for 17 patients with a mean of 21 months. IKCD and Lysholm-Tegner criteria were assessed. Laxity was measured at maximal manual traction using a KT 1000.

Results: Overall IKDC outcome was 2A, 10B, 4C, and 1D. Differential laxity at maximal manual traction, evaluated for the 12 patients with a healthy contralateral knee was 2.7 ± 1.3 mm (versus 1.7±1.9 mm in the control series). Mean pre-postoperative gain in the 17 patients was 5.4 ± 3 mm (versus 5.6 ± 2.4 mm in the control series). The predominant sign was residual pain (11/17). Pain was generally moderate and induced by exercise. Pain at the site of graft harvesting was frequent during the six months after surgery (11 cases) but rare after one year (2 cases).

Discussion: Due to the cartilage and meniscal history of this population of patients who had undergone several repairs of the ACL, the results were satisfactory and little different from those obtained with the same primary procedure in a control group. The residual laxity study showed that the mechanical quality of the transplant was good. Histology studies published on repeat patellar tendon harvesting have been discordant.

Conclusions: Repeat harvesting of the patellar tendon for ACL repair appears to be an excellent alternative since it is thicker than the primary transplant and thus fills the bone defects better than other transplants (particularly hamstring).