Introduction and Aims: To assess and compare treatment of pelvic Ewing’s sarcoma, particularly extracorporeal irradiation (ECI) and re-implantation of bone segments. Method: We reviewed all patients presenting to the New South Wales Bone Tumor Service with Ewing’s sarcoma of the pelvis from 1995 until 2003. All received chemotherapy. There were 17 patients. Resection was performed in 14 cases: 12 were reconstructed by ECI and re-implantation of the bone segment; one with autograft and THR; one with allograft and THR. Three patients with sacral lesions had chemotherapy and radiotherapy only. All margins were clear. All patients were clinically and radiologically reviewed. Three scoring systems were used: The Musculoskeletal Tumor Society score (MSTS), the Toronto Extremity Salvage Score (TESS), and the Harris Hip Score (HHS). Results: The average age at presentation was 18 years (range six to 35). There were seven males and 10 females. One patient presented with metastatic disease. Survivor follow-up ranged from 25 to 105 months (mean 55). In those who developed metastases these were detected at a mean of 27 months (range one to 79). Deaths occurred at a mean 31 months (range eight to 65). Fourteen underwent surgery. Seven had THR as part of their reconstruction. There have been no local recurrences after surgery. Six patients have died, 11 patients are alive (65%), one with metastatic disease. Overall disease-free survival is 59%. The disease-free survival in those who underwent ECI and re-implantation is 75% (minimum two-year follow-up). Functional outcome is good. The TESS mean was 83 (range 60–100). The MSTS score mean 85 (range 60–97). The HHS mean 92 (range 67–100). Radiologically solid bony union at the osteotomy sites was the norm. Lysis existed at two periacetabular osteotomies, around the posterior iliac crest of one osteotomy, and a fibrous union occurred at one sacro-iliac joint with breakage of the sacro-iliac screws. There have been no graft fractures. Conclusion: The best surgical management for these difficult cases is extracorporeal irradiation and re-implantation of bone segments

Limb Salvage surgery is the preferred treatment for malignant tumours of bone. This may require resection – arthrodesis, endoprosthetic replacement or allograft reconstruction. We have re-implanted the patient’s bone for reconstruction of the defect after debulking the tumour and irradiation in ten patients. All had grade IIB sarcomas of the pelvis, humerus, tibia and metacarpal. Median overall survival was 24 months (maximum 69 months). Four patients are alive at the most recent follow-up. One of them has metastatic disease and local recurrence while others remain free of disease. One patient has had pathological fracture through the irradiated bone that healed with conservative measures. One developed avascular necrosis of the femoral head and required resurfacing arthroplasty of the hip. The pelvic sarcoma continues to be a challenge. Resection, extracorporal irradiation and re-implantation may offer some hope but remain experimental

Introduction: Amputation of digits/thumb is quite common in industrial areas of Karachi. Loss of digits/ thumb can lead to physical and functional disability and subsequent loss of job of a worker. Amputated digits/ thumbs can be re-implanted with adequate functional outcome provided microsurgical expertise, are available.

Materials and Method: A retrospective study was done to determine the outcome of reimplanted digits/thumb performed at AKUH from 1997 to 1999. All the patients with primary reimplantation of digits/thumb were include in the study while patients with primary stump formation, were excluded. The data was collected through a questionnaire after reviewing clinical records of patients. The important variables being demographic data, mechanism of injury, type of amputation, duration of amputation, digit involved and site of amputation, procedure performed (reimplantation / revascularization) complication, revision surgery, follow up and outcome. The functional outcome was measured using Chen’s criteria. The analysis was done using EPI info statistical package.

Results: Reimplantation was performed in 20 patients and revascularization was done in 4 patient from 1997 to 1999. The age ranged from _ year to 55 year with average age of 20 years. There were 22 male and 2 female patients. There were 8 cases of thumb, 14 cases of digits (index finger5, middle finger 4, ring finger 3 and little finger 2) and 2 cases of toe reimplantation.

The mechanism of amputation was industrial accidents in 18 cases and domestic injuries in 6 cases. The various types of amputations were a avulsion type in 3 cases, guillotine in 7 and amputation with localized crush in 14 cases. These patients presented to us with average duration of 7 hours after injury ranging from 4–10 hours. Ten cases were operated under L/A and 14 cases under G/A. Four of 24 cases required revision surgery due to venous block. The average follow up was 16 months ranging from 3 months–3 years.

The results were graded according to Chen’s criteria. Four cases had grade I, 9 had grade II and 1 grade III functional outcome according to Chen’s criteria.

Discussion: Although reimplantation of digits/thumb is successful procedure with refined microsurgical techniques. These procedures are long, tedious and demanding. Patient with re-implanted digits return to their job early but still have few complications like fingertip atrophy and diminished two point discrimination. Benefits and draw backs of reimplantation should be weighed before under taking reimplantation procedure.

Extracorporeal Irradiation and Reimplantation (EIR) of tumor bearing bone segments is an alternative reconstruction method for major osseous resections. In contrast with endoprosthetic reconstruction, EIR is a biologic solution and after a prolonged healing and remodeling period it is expected to create a structural and metabolic almost normal bone.

After oncologic resection the bone segment is cleaned from adhered soft tissues and send to irradiation which kills malignant and normal cells. Reimplantation consists of fixation, mostly by plates, vascularised fibular graft insertion in the medullary canal, iliac bone graft in critical sites and ligamentous sutures.

Since 2001 fifteen patients were submitted to EIR in our institution. Resections affected seven distal femurs, four proximal tibias, one acetabulum, one iliac bone and the proximal forehand bones once which bear 11 osteosarcomas, 2 Ewing’s sarcomas, 1 chondrosarcoma and 1 rhabdomyosarcoma. There were six males and nine females with age ranging from five to 55 years. Ten patients were submitted to osteoarticular reconstructions, three to intercalary and two to partial pelvis reconstructions.

Local recurrence leading to amputation occurred in one patient and resection of an infected innominate bone occurred once. Three patients died two to nine months after surgery because of their disease. Five patients had metaphyseal fractures after one to 14 months after surgery. Four patients had no fracture; three of them had intercalary resections. The patient with osteoarticular resection and no fracture had his metaphyseal region injected with cement which prevented fracture and after 23 months have not developed osteoarthritis.

All the cases in which a vascularised fibular graft was implanted progressive fusion of the living and dead bones were observed.

As a conclusion EIR is a good alternative for intercalary resections. For osteoarticular resections improvement of the method are necessary to prevent fracture and ligamentous laxity.

Background. Well-fixed cementless stems are sometimes needed to be extracted in patients with complications including periprosthetic infection, stem-neck breakage or trunnionosis. The purpose of this study was to report the clinical outcome in patients undergoing re-implantation surgery following removal of a well-fixed porous-coated cementless stem by the femoral longitudinal split (FLS) procedure(Fig.1, Fig.2). Methods. We conducted a retrospective study and radiographic review of 16 patients who had undergone re-implantation following the FLS procedure to remove a well-fixed stem due to periprosthetic infection, stem-neck breakage or trunnionosis. The study group consisted of 2 men and 14women with an average age of 68.4 years. Mean follow-up was 33.1± 25.0 months. Operation time, intraoperative bleeding, complications, causes of re-operation and clinical score were evaluated and the Kaplan-Meier method was used to evaluate the longevity of the stem. Results. The average operation time was 272±63 minutes and intraoperative bleeding was 420±170 ml. Although postoperative dislocation occurred in 5 hips and sinking of the stem was found in 3 hips after surgery, no progression of the stem sinking was observed and the clinical JOA and JHEQ scores were both improved after re-implantation surgery. Re-implantation surgery with Zweymüller-type stems, which are shorter than those removed, revealed evidence of osseointegration of the stem without femoral fracture. Kaplan-Meier survival analysis of stem revision for any reason as the end point revealed 70.3% survival at 9 years (Fig.3). Conclusion. The FLS procedure is expected to confer successful clinical results without loosening of the stem, following safe extraction of well-fixed porous-coated cementless stems without fracture and will allow re-implantation with shorter cementless stems than those removed. For any figures or tables, please contact the authors directly

Aim. The effectiveness of mandatory joint aspiration prior to re-implantation in patients with a cement spacer already in place is unclear. The aim of this study was to evaluate the role of culturing articular fluid obtained by joint aspiration prior to re-implantation in patients who underwent a two stage septic revision. Method. A retrospective observational study was conducted, assessing51 patients that underwent a two stage septic hip or knee revision from 2010 to 2017. According to the results of intraoperative cultures, after the first stage revision each patient was treated with an antibiotic protocol for 6–8 weeks. Following two weeks without antibiotics, a culture of synovial fluid was obtained. Synovial fluid was obtained by direct joint aspiration in cases of knee spacers by and by joint aspiration guided by fluoroscopy in the theatre room in cases of hip spacers. Synovial fluid was transferred into a Vacutainer ACD. ®. flask. Samples were processed and analysed in the microbiology laboratory. Gram stains were performed and the sample was subsequently transferred into a BacALERT bottle (bioMérieux, France) and incubated in a BacALERT instrument for seven days. Results of these cultures were recorded and compared with cultures obtained during re-implantation surgery. Results. Of the 51 patients analysed, 9 were excluded because joint aspiration was not performed or the samples were not correctly processed. The remaining 42 patients (21 hip and 21 knee spacers) were included in the final analysis. In 40 cases, the culture of synovial fluid was negative while in the remaining two cases (hip spacers) no analysis was possible due to dry aspiration. In 5 of the patients, two or more intraoperative synovial fluid cultures taken during the re-implantation surgery were positive. Conclusions. Although in theory, synovial fluid culture may provide useful information regarding the infection status of the joint, in our study, we found no evidence to support mandatory joint aspiration prior to re-implantation in patients with a cement spacer in place

Two-stage reconstruction with total implant removal and re-implantation after infection control is considered the gold standard treatment forinfection after hip arthroplasty. However, removal of the well-fixed stem or cup may cause substantial bone loss and other complications, thereby making reconstruction difficult. We evaluated whether an infection posttotal hip arthroplasty can be treated without removal of the radiographically and clinically well-fixed femoral stem or acetabular cup. Patients with a chronic infection aftertotal hip arthroplasty, with a radiographically well-fixed, cementless stem or cup, were selected. During the first surgical stage, we retained the stem or cup if we were unable to removethese with a stem or cup extractor. An antibiotic-impregnated cement spacer was then implanted. After control of infection (C-reactive proteinlevel within normal value), we performed the secondstage of re-implantation surgery. Treatment failure was defined as uncontrolled infection requiringremoval of the retained implant. From January 2004 to December 2013, 16 patients underwent partial component-retained 2-stage reconstruction. Thirteen patients (81.3%) were free of infection, with a mean follow-up time of 5 years. The remaining 3 patients, who had high-risk comorbidities and, of whom, 2 were infected by high-virulence organism, had uncontrolled infection and required furthersurgery to remove the retained implant. We conclude that partial component-retained 2-stage reconstruction could be an alternative treatment option for chronic infection afteran uncemented total hip arthroplasty with a radiographically and clinically well-fixed component in selected patients, who are notimmunocompromised and are infected by a low-virulence organism

The aim of this study was to compare the results of resection arthroplasty with two-stage re-implantation procedure performed for peri-prosthetic infection of the hip. Patients who have had a resection arthroplasty can expect to have less pain, but their functional recovery is inferior to that which can be obtained after a two-stage re-implantation. Resection arthroplasty is usually unacceptable as a definitive solution for relatively young and active patients. Possible options for the operative treatment of a periprosthetic infection include debridement with retention of the prosthesis, immediate one-stage exchange arthroplasty, and excision arthroplasty – either as a definitive procedure or as the first of a two-stage reconstructive procedure. The choice of a particular treatment is influenced by a number of factors. At the Department of Orthopaedic Surgery in Hradec Králové we performed resection arthoplasty of the hip in 67 patients between 1984 and 1998. Mean age was 67 years (range 44–91). We were able to follow-up 33 of these patients in 1999. At follow-up, replacement of the total hip prosthesis in two stages had been carried out in 10 of the 33 patients. In 23 patients (11 male, 12 female) the resection arthroplasty had been present for an average of five years. In the remaining ten patients (3 male, 7 female) a total hip reimplantation had been performed after an average of 17 months (range 3 to 63). Mean follow-up after reimplantation was four years. The Harris hip score was calculated for the individual patients during follow-up. The Harris hip score was 66 in the re-implantation group compared to 57.5 in the patients with resection arthroplasty. Personal satisfaction and hip function were better after the two-stage re-implantation procedure

The aim of this study is to compare the results of resection arthroplasty with two-stage re-implantation procedure performed for peri-prosthetic infection of the hip. Patients who have had a resection arthroplasty can expect to have less pain, but their functional recovery is inferior to that which can be obtained after a two-stage re-implantation. Resection arthroplasty is usually unacceptable as a definitive solution for relatively young and active patients. Possible options for the operative treatment of a periprosthetic infection include debridement with retention of the prosthesis, immediate one-stage exchange arthroplasty, and excision arthroplasty – either as a definitive procedure or as the first of a two-stage reconstructive procedure. The choice of a particular treatment is influenced by a number of factors. At the Department of Orthopaedic Surgery in Hradec Králové we performed resection arthoplasty of the hip in 67 patients between 1984 and 1998. Mean age was 67 years (range 44–91). We were able to follow-up 33 of these patients in 1999. At follow-up, replacement of the total hip prosthesis in two stages had been carried out in 10 of the 33 patients. In 23 patients (11male, 12 female) the resection arthroplasty had been present for an average of five years. In the remaining ten patients (3 male, 7 female) a total hip reimplantation had been performed after an average of 17 months (range 3 to 63). Mean follow-up after reimplantation was four years. The Harris hip score was calculated for the individual patients during follow-up. The Harris hip score was 66 in the re-implantation group compared to 57.5 in the patients with resection arthroplasty. Personal satisfaction and hip function were better after the two-stage re-implantation procedure

The management of a bacterial periprosthetic infection by two-stage re-implantation should be presented using an implanted application spacer for antibiotics to maintain mobility and soft tissue balance and ensure simultaneous local delivery of antibiotics. Indication is an acute periprosthetic infection, acute and chronic course of the infection with unknown spectrum of organism, hardly to treat and with a probable loss of mobility due to protracted immobilization after implant removal. Acute infections with a known spectrum of organisms that can be controlled by synovectomy and antibiotic treatment or by one-stage re-implantation are contraindications for this treatment. Spacers are available for hip and knee replacements including surface replacements of the knee. First a complete synovectomy is performed; the implant bed is then prepared for implantation of the application spacer for antibiotics. Silicone catheters are advanced through two separate drill holes into the intramedullary canal and then inserted into the perforated implant stems. Daily parenteral doses of antibiotics in parenteral doses are delivered through the percutaneous silicone catheters directly into the intramedullary canal. The application spacer for antibiotics allows daily physiotherapy and even mobilization on a CPM device. Partial weight bearing may even be allowed, if there is sufficient stability. Once the CRP values have decreased to normal levels, the definitive implant is placed using antibiotic-impregnated cement according to current resistance studies. 36 patients have been treated with this method since 1993. Two-stage re-implantation of a total knee was performed in 20 cases, and re-implantation of a total hip in 16 cases. The longest postoperative follow-up period is now 10 years. Till now, no revision surgery has been required on a joint treated in this manner, and no periprosthetic re-infections have been observed. In the knee, a range of motion of 0/0 /106 degrees was achieved after an average follow-up period of 6.1 years. In the hip, values of 10/0/110 degrees were achieved after an average of 6.3 years. Revision surgery for infection included cases of fungal and tubercular infection. A postoperative Hospital for Special Surgery rating of 79.5 was achieved in the knee and a rating of 81.3 in the Harris hip score

In recent years articulating cement spacers have been used to treat infected knee arthroplasty. The aim has been to better maintain tissue planes and joint mobility thereby improving second stage re-implantation surgery. Two groups of patients treated for infected knee arthroplasty were reviewed. Twenty-six patients with articulating and forty patients with static antibiotic-impregnated methyl-methacrylate spacers were compared. The articulating spacers demonstrated easier surgical exposure at second stage and improved range of knee motion after re-implantation. There was no compromise in the rate of infection eradication with articulating spacers. Bone loss at revision was independent of spacer type. To compare the results of patients treated with articulating versus static antibiotic-impregnated spacers for infected knee arthroplasty. Articulating cement spacers facilitate re-implantation surgery by maintaining tissue planes and joint mobility without compromising joint stability or eradication rate of infection. Patients demonstrate better range of motion and less complications related to the extensor mechanism with the articulated spacer. Antibiotic impregnated methyl-methacrylate spacers have become a mainstay in two-stage revision arthroplasty for sepsis. It is thought that articulating cement spacers facilitate prosthesis re-insertion by better maintaining tissue planes and joint mobility between stages. In the articulating group fewer extensile exposure methods were required at second stage prosthesis reimplantation (19% vs 36 %). No tibial tuberosity osteotomies have been required since using the articulating spacer. The articulating group demonstrated a significantly improved range of flexion compared to the static group(106 vs 97 degrees- p=0.045) and had fewer patients with significant loss of extension or quadriceps lag. Eradication of infection was improved in the articulating group (92% vs 82%) but at shorter average follow-up. The need for augments and stabilized prostheses at revision surgery as a measure of bone loss was no different between the groups but was related to the number of prior surgical procedures. Twenty-six patients treated with articulating spacers were compared to a matched consecutive group of forty patients treated with static spacers. Minimum follow-up was twelve months from second stage re-implantation (average twenty-two months articulating, forty months static). Funding: No direct funding from any commercial source has been received for this study. The primary author’s fellowship position is partially funded by Smith and Nephew Richards Inc

In recent years articulating cement spacers have been used to treat infected knee arthroplasty. The aim has been to better maintain tissue planes and joint mobility thereby improving second stage re-implantation surgery. Two groups of patients treated for infected knee arthroplasty were reviewed. Twenty-six patients with articulating and forty patients with static antibiotic-impregnated methyl-methacrylate spacers were compared. The articulating spacers demonstrated easier surgical exposure at second stage and improved range of knee motion after re-implantation. There was no compromise in the rate of infection eradication with articulating spacers. Bone loss at revision was independent of spacer type. To compare the results of patients treated with articulating versus static antibiotic-impregnated spacers for infected knee arthroplasty. Articulating cement spacers facilitate re-implantation surgery by maintaining tissue planes and joint mobility without compromising joint stability or eradication rate of infection. Patients demonstrate better range of motion and less complications related to the extensor mechanism with the articulated spacer. Antibiotic impregnated methyl-methacrylate spacers have become a mainstay in two-stage revision arthroplasty for sepsis. It is thought that articulating cement spacers facilitate prosthesis re-insertion by better maintaining tissue planes and joint mobility between stages. In the articulating group fewer extensile exposure methods were required at second stage prosthesis reimplantation (19% vs 36 %). No tibial tuberosity osteotomies have been required since using the articulating spacer. The articulating group demonstrated a significantly improved range of flexion compared to the static group(106 vs 97 degrees- p=0.045) and had fewer patients with significant loss of extension or quadriceps lag. Eradication of infection was improved in the articulating group (92% vs 82%) but at shorter average follow-up. The need for augments and stabilized prostheses at revision surgery as a measure of bone loss was no different between the groups but was related to the number of prior surgical procedures. Twenty-six patients treated with articulating spacers were compared to a matched consecutive group of forty patients treated with static spacers. Minimum follow-up was twelve months from second stage re-implantation (average twenty-two months articulating, forty months static). Funding: No direct funding from any commercial source has been received for this study. The primary author’s fellowship position is partially funded by Smith and Nephew Richards Inc

The October 2013 Oncology Roundup. 360 . looks at: En bloc resection, irradiation and re-implantation; Metastasis and osteosarcoma; Mobile spine and osteosarcoma; Denosumab miraculous for GCT; Fevers, megaprostheses and sarcomas; PET and prognosis; Canine sarcomas not so different?; Bone cement and giant cell tumours

Introduction. Prosthetic joint infection (PJI) is an devastating complication after total hip arthroplasty (THA). The common treatment in the US is a two-stage exchange which can be associated with significant morbidity and mortality. The purpose of this study was to analyze complications in the treatment course of patients undergoing two-stage exchange for PJI THA and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of PJI after THA from January 2005 – December 2017 at a single institution. Complications were categorized as medical or surgical, divided into three intervals: (1) inter-stage, (2) early post-reimplantation (<90 days) and (3) late post-reimplantation (> 90 days). Minimum follow up was one year. Success was based on the Musculoskeletal Infection Society (MSIS) definition. Results. 185 hips underwent first stage of planned two stage exchange. The median age was 65 (IQR 18). There were 93 males and 92 females. 73 patients had a complication during treatment. 13.5% (25/185) of patients experienced a medical complication and 28.1% (52/185) a surgical complication. There was a 14.1% (26/185) mortality at a median of 2.5 years (IQR 4.9). 51(29%) had complications during the interstage period, most common being recurrence of infection requiring a spacer exchange (48.6%). 2 patients died and 2 patients failed to progress to the second stage. 22(12%) complications following re-implantation, most commonly persistence /recurrence of infection (31%). 183/185 patients that initiated a two stage exchange were re-implanted, only 65% (120/185) were successfully treated with or without antibiotic suppression at one-year without additional surgery. Conclusions. While 2 stage exchanges for PJI in THA have been reported as successful, there are few reports of the complications during the process. In our series, significant numbers of patients experienced complications, often during the interstage period, highlighting the morbidity of this method of treatment

Background: Infection remains the single most devastating complication of joint arthroplasty. In cases of established prosthetic infection, where implant retention is not feasible, there is limited consensus on an optimum management protocol. Aim: To assess the outcome of revision for infected hip prostheses using a novel treatment regimen. Materials and Methods: Retrospective study of a consecutive case series of 40 patients with late chronic hip joint prosthetic infection treated by a single surgeon over a 4 year period. The mean interval between index arthroplasty and revision for infection was 40 months, with patients having prior symptoms of infection for a mean of 22 months. The treatment protocol consisted of a two stage exchange with removal of infected components via a posterior approach incorporating an extended trochanteric osteotomy, insertion of an interim antibiotic eluting cement spacer and re-implantation of an extensively coated uncemented prosthesis on the femoral side. Systemic antibiotic treatment following each stage consisted of an abridged course of 5 days post operative intravenous administration followed by complete cessation of anti-microbial therapy. The mean interval between implant removal and re-implantation was 111 days. Results: At a mean follow up of 29.6 months (minimum 12 months), there were 2 cases of recurrent prosthetic infection. Dislocation following the second stage occurred in 7 patients. There was one mortality and one case of post operative sciatic nerve palsy. The Harris hip score increased from a pre-operative mean of 43.8 to a post operative mean of 83.9. At follow up, no patient had required revision for aseptic loosening or mechanical instability on the femoral side. Conclusion: The combination of effective staged surgical joint debridement, a shortened post operative course of systemic antibiotic treatment and an adequate latent period before re-implantation has led to encouraging early results in this series of revised chronic hip joint prosthetic infections

Background: Antibiotic-loaded spacers and cement nails are commonly used in patients undergoing a two-stage implant exchange procedure for treatment of prosthetic joint infection (PJI). During re-implantation 2–6 weeks after implant removal, tissue specimens are collected to document successful eradication of infection. However, these specimens have limited sensitivity, especially in patients receiving antimicrobial treatment. We investigated the value of sonication of removed spacers and cement nails. Methods: We prospectively included patients in whom a spacer or cement nail was removed from January 2007 through April 2009 during a two-stage exchange procedure. The removed temporary device was sonicated in a container with Ringer’s solution in an ultrasound bath for 5 min at 40 kHz (as described in . NEJM. 2007. ;. 357. :. 654. ). The resulting sonication fluid was cultured aerobically and anaerobically for 10 days. In parallel, > 2 tissue samples were collected for conventional cultures on blood agar plates and enrichment broth. PJI was defined as visible purulence, acute inflammation on histopathology, sinus tract or significant microbial growth in tissue or implant sonication cultures. Results: In this ongoing study, 28 spacers and 10 cement nails from patients with confirmed PJI were included (median age 75 y; range 49–86 y). All devices were impregnated with antibiotics (gentamicin and/or vancomycin) and were placed in the hip (n=21), knee (n=9) or shoulder joint region (n=7). At the time of explantation, the following pathogens were isolated: coagulase-negative staphylococci (n=19), Staphylococcus aureus (n=7), Streptococcus agalactiae (n=3), Propionibacterium acnes (n=5) and mixed infection (n=4). All patients received systemic antibiotics for a median of 19 days (range 11–42 days) before removal of the spacer/nail. At the time of re-implantation, tissue cultures were negative in all 38 patients, whereas sonication cultures showed growth of Propionibacterium acnes in 2 of 38 patients (5%) with a hip and shoulder spacer, both in significant numbers (150 and 550 colonies/ml sonication fluid, respectively). These organisms were probably present as mixed infection already at the time of explantation, but were missed due to overgrowth due to another organism (S. aureus in one patient and coagulase-negative staphylococci in another). Both patients were not initially treated for the Propionibacterium acnes infection, but the treatment was given after re-implantation. Conclusion: Sonication of removed spacers is a suitable approach to identify persistent infection in patients with a two-stage exchange. Sonication may replace the current standard approach consisting of multiple tissue specimens in order to document successful eradication of infection

Introduction and Aims: To compare the results of patients treated with articulating versus static antibiotic-impregnated spacers for infected knee arthroplasty. Method: All patients undergoing two-stage revision knee arthroplasty for sepsis in the last five years were reviewed. Twenty-six patients had been treated with articulating spacers. This group was compared to 36 patients treated with static spacers. The articulating spacer technique had been adopted more recently than the static technique. Minimum follow-up was 12 months from second stage re-implantation (average 22 months articulating, 40 months static). Patients were compared in terms of the need for extensile exposures required for re-implantation, range of motion at most recent review, eradication of infection and augmentation required on revision implants. Results: In the articulating group, fewer extensile exposure methods were required at second-stage prosthesis re-implantation (19% vs 36%). No tibial tuberosity osteotomies have been required since using the articulating spacer. The articulating group demonstrated a significantly improved range of flexion compared to the static group (106 vs 97 degrees – p=0.045) and had fewer patients with significant loss of extension or quadriceps lag. Eradication of infection was improved in the articulating group (92% vs 82%) but at shorter average follow-up. The need for augments and stabilised prostheses at revision surgery as a measure of bone loss was no different between the groups but was related to the number of prior surgical procedures. Conclusion: Articulating cement spacers facilitate reimplantation surgery by maintaining tissue planes and joint mobility without compromising joint stability or eradication rate of infection. Patients demonstrate better range of motion and less complications related to the extensor mechanism with the articulated spacer

Introduction: Osteoblasts precursors reside in the marrow and small numbers circulate in the blood. Our previous work demonstrated an increase in circulating cells following fracture in humans. Skeletal injury is recognised to stimulate a distant osteogenic response. We hypothesised that in response to fracture, some integral osteoblasts are recruited via the circulation from remote bone marrow sites. Method: We established a fracture union model in 3-month-old, male, New Zealand White rabbits and reimplanted labelled autologous osteoblast precursors. At date of submission we have 20 rabbits allocated into 4 groups. Three groups had labelled cells re-implanted, whilst the fourth control group did not receive cells. In groups I, II and III the cells were re-implanted into the fracture gap, into the circulation and into a remote bone marrow cavity respectively. There were six animals in groups I and IV, and four in both II and III. All animals had bone marrow harvested from their right tibia by saline flush. The mononuclear cells were isolated and culture-expanded in osteogenic medium for 3 weeks. Fluorescent reporter molecules were incorporated into the cell membranes, 24 hours prior to re-implantation of the cells into the fracture model. A 3 mm ulnar defect was preformed in all the animals. In groups I–III this was established 48 hours prior to cell re-implantation. The animals were sacrificed at least 3 weeks after fracture surgery. Representative samples of the fracture callous, lung, liver, spleen and kidney were harvested from all animals and cryo-sectioned. Using confocal microscopy, the labelled cells were expressed as the average in 5 high power fields for each solid tissue. In addition, cyto-spins were made from blood and marrow and the cell number expressed as a percentage of the total cells. Results: In group I, labelled cells were identified in the fracture callous, establishing their viability in vivo. Following intravenous re-implantation a smaller number of labelled cells were identified in the callous. When the cells were re-implanted into a remote marrow site, the number of cells in the callous was greater than after venous reimplantation, but less numerous than those in group I. In all sections, these labelled cells appeared on trabecular surfaces in an osteoblastic fashion, but occasionally they were surrounded by osteoid, corresponding to osteocytes. A small number of labelled cells were found in the blood, bone marrow, lung, liver and spleen of all animals in groups I–III. No labelled cells were identified in the kidney tissue. Discussion and Conclusions: We have demonstrated that cells from remote sites are integral in fracture healing. Their presence in callous following venous administration supports recruitment via the circulation. This preliminary data is a proof of concept. This is an exciting new phenomenon, which could provide alternatives for harvesting skeletal progenitor cells and for their delivery in the treatment of bony pathology

There remains to be substantial debate on the best treatment of the infected shoulder arthroplasty. Infection after shoulder arthroplasty is an uncommon but devastating complication with a reported incidence from 0 to 4%. The most common organism responsible for infection following rotator cuff surgery, instability surgery, ORIF proximal humerus fractures, and shoulder arthroplasty is Prop. Acnes. A thorough history is important because many patients have a history of difficulty with wound healing or drainage. Prop. Acnes typically does not start to grow until day 5, therefore it is critical to keep cultures a minimum of 10 to 14 days. Diagnosis can be difficult, particularly among patients undergoing revision surgery. The majority of patients with a low grade infection do not have overt signs of infection such as erythema or sinus tracts. Preoperative lab values as well as intraoperative pathology have been shown to be unreliable in predicting who will have positive cultures at the time of revision surgery. There are a number of options for treating a patient with a post-operative infection. Critical variables include the timing of infection, status of the host, the specific organism, status of implant fixation, and the status of the rotator cuff and deltoid. One of the most frequently employed options for treating the infected shoulder arthroplasty is two-stage re-implantation. However, the rate of complications with this technique as well as residual infection remains high

Introduction. Metaphyseal cones with cemented stems are frequently used in revision total knee arthroplasties (TKAs). However, if the diaphysis has been previously violated (as in revision of a failed stemmed implant), the resultant sclerotic canal can impair cemented stem fixation, which is vital for cone ingrowth and long-term fixation. We report the outcomes of our novel solution to this problem, in which impaction grafting and a cemented stem in the diaphysis was combined with an uncemented metaphyseal cone for revision TKAs with severely compromised bone. Methods. A metaphyseal cone was combined with diaphyseal impaction grafting and cemented stems in a novel fashion for 35 revision TKAs. Mean age at revision TKA was 70 years, with 63% being male. Patients had a mean of 4 prior knee arthroplasty procedures. Indications for the revision with this construct were aseptic loosening (80%) and two-stage re-implantation for periprosthetic infection (PJI; 20%). Mean follow-up was 3 years. Results. Survivorship free from revision of the cone/impaction grafting construct due to aseptic loosening was 100% at 5 years. Survivorships free from any revision of the cone/impaction grafting construct and free from any reoperation were 92% and 73% at 5 years, respectively. Six knees (17%) required a reoperation (4 for infection/wound issues and 2 for periprosthetic fractures). Radiographically, 97% of cones were ingrown (1 loose cone in setting of PJI). In all but one case, impacted diaphyseal bone graft appeared to have incorporated radiographically. Conclusions. When presented with a sclerotic diaphysis and substantial metaphyseal bone loss, this innovative technique combining diaphyseal impaction grafting with a metaphyseal cone provided near universal success in regards to implant fixation. Moreover, radiographs revealed incorporation of the bone graft, and ingrowth of the cones. While long-term follow-up is required, this novel technique provides an excellent option in the most difficult of revision TKAs. For figures, tables, or references, please contact authors directly