Purpose: We report cancerological and functional outcome in 41 patients who underwent interilioabdominal disarticulation for malignant tumours. Material and methods: This retrospective series included 27 men and 14 women, mean age 49 years, most of whom underwent surgery for chondrosarcoma. In ten patients, the disarticulation followed a resection-reconstruction procedure. In five patients, it followed curettage or contaminated margin resection. For seven patients it was performed after radiotherapy alone. None of the patients had metastatic dissemination prior to surgery. The resection margins were in healthy tissue in 24 cases and contaminated in 17. Mean follow-up was 62 months. Results: Twenty-eight patients died from their disease and one died from pulmonary embolism. At last follow-up, among the 13 living patients, five had local or general relapse. For the 17 patients who had contaminated resection margins, ten developed a recurrent tumour compared with five recurrent tumours among the 25 patients with resection margins in healthy tissue. Mean five-and ten-year survival rates were 30% and 25% respectively. Initial treatment, tumour size and tumour histology did not have any significant effect on prognosis. The only factor with a significant effect on survival was the quality of the resection margins. All patients were able to walk with two crutches. Discussion: Interilioabdominal disarticulation is a very mutilating procedure. Since the development of conservative surgery of the pelvis, indications for interilioabdominal disarticulation are generally limited to very voluminous endopelvic tumours with vessel and nerve invasion. For local recurrence after surgical resection of the pelvis or proximal femur, especially in patients with infection or radiated tissue, interilioabdominal disarticulation may be the only solution providing satisfactory cancerological resection. Careful exploration of the locoregional and general extension is necessary before proposing this mutilating procedure, with its inherent psychological and functional impact, in order to properly select patients free of metastasis who could benefit from the cancerological resection provided by inter-ilioabdominal disarticulation

Purpose: To determine the wound healing rate, perioperative mortality and ambulatory status of patients following knee disarticulation. Method: Retrospective review of all cases performed by one surgeon at tertiary center. Charts reviewed for demographic data, surgical and follow-up data. Ambulatory status preop and postop graded after Volpicelli et al. Descriptive statistics applied. Results: 34 knee disarticulations in 28 patients. 3 perioperative deaths (11%). Report on 31 procedures in 25 patients with mean follow-up of 7 months. 20 males, 5 females. Mean age 73 (55–92). PVD 21/25. Diabetes Mellitus 13/25 (52%). Chronic infection 2, Scleroderma 1 and squamous cell carcinoma 1. Primary wound healing 25 (81%). Delayed healing 6 (19%). Reoperation 1. Revision of amputation 0. Mean ambulatory status preop 2.5/6. Mean ambulatory status postop 1.8/6. Conclusion: Knee disarticulation is a reliable surgical procedure with 81% primary healing in high risk population. Knee disarticulation should be considered as an option to above knee amputation for patients with PVD and complications of diabetes

An anterior skin flap taken from the instep can be used to cover the bone ends in disarticulation of the ankle when ulceration or necrosis of the heel prevents the use of the heel flap for a conventional Syme’s amputation. From 1995 to 2003 December, we performed ankle disarticulation by using anterior flap after primary radical debridement in 42 cases with traumatic foot amputation injured by antipersonnel land mines. In all our cases, we observed wound healing in 2 weeks without any problems. The patients were advised to use a cylindrical bootee for indoor walking in third week. After 1–1.5 month, we put plastazote pad on stump end for prosthesis fitting, and for ourdoor walking the patients used prosthesis which would combine partial end-bearing and partial weight bearing on the patellar tendon. Ground contacting and standing without a prosthesis were also acceptable. We observed the advantages of prosthesis fitting. For instance, there is no need to open a window on the prosthesis socket for fitting and it is easier to fit the slender stump into the prosthesis. In early fitting we did not come across any problems about the slipping of the flap from stump as seen in conventional Syme’s amputation. In short and long term follow-ups, we found that the patients did not complain much about their prosthesis. For all these reasons, we think that ankle disarticulation with anterior flap rather than transtibial amputation should be preferred in patients with traumatic foot amputation since conventional Syme’s amputation can not be performed in heel injuries

Pressure ulcers are a common and recurrent clinical condition in paraplegic patients, requiring specialized equipment and care, as well as surgical interventions in order to treat them. This is especially true whenever and infection is declared, which will delay or impair ulcer epitelization. These surgical interventions require a good use of various myocutaneos flaps to cover all defects. Problem arises whenever there is not enough flap tissue to cover the entire ulcer, or when multiple surgeries to correct previous ulcers have already been performed.

Our goal is to describe the use of a last resort surgical technique for covering infected pressure ulcers.

This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams.

We present the case of a 30-years-old man, paraplegic for 10 years due to motor vehicle accident with spinal cord injury. Since the accident, and although he used adapted equipment and pressure relief mattresses and wheelchair cushions, he developed recurrent, infected ulcers in the perineal and sacral area, being operated on for multiple times by the Plastic and Reconstructive Surgery (PRS) department, for surgical debridement and ulcer coverage with tensor faciae latae and hamstrings myocutaneous flaps.

Despite all treatment, patient developed a stage IV perineal ulcer, which ranged from his left great trochanter to the right buttock, and a simultaneous stage IV sacral ulcer. Both ulcers were infected with meticilin-resistent Staphylococcus aureus (MRSA), sensitive to vancomycin. The patient's left hip joint was also infected (due to a direct trajectory to the perineal ulcer) and subluxated (due to absence of soft tissue support).

A multidisciplinary team assembled and decision was made to disarticulate the patient's left hip, debride and irrigate extensively the surgical site, and use a double gastrocnemius myocutaneous fillet flap in-continuity, in a surgical collaboration between the Orthopaedics and PRS department. This should provide satisfactory soft tissue ulcer coverage as well as facilitate antibiotics penetrance and infection eradication.

Surgery went without complications and the patient healed uneventfully. He resumed unrestricted positioning for sitting and wheelchair mobilization. Now, at two years follow-up, the patient still has no recurrence of either the ulcer or the infection.

This surgical technique provided robust soft tissue coverage for the ulcers, as well as an important aid for infection control. It proved to be a viable option in a paraplegic patient, when more traditional flap techniques can no longer be used and with a recurrent infection.

There is a paucity of data available for the use of Total Femoral Arthroplasty (TFA) for joint reconstruction in the non-oncological setting. The aim of this study was to evaluate TFA outcomes with minimum 5-year follow-up. This was a retrospective database study of TFAs performed at a UK tertiary referral revision arthroplasty unit. Inclusion criteria were patients undergoing TFA for non-oncological indications. We report demographics, indications for TFA, implant survivorship, clinical outcomes, and indications for re-operation. A total of 39 TFAs were performed in 38 patients between 2015–2018 (median age 68 years, IQR 17, range 46–86), with 5.3 years’ (IQR 1.2, 4.1–18.8) follow-up; 3 patients had died. The most common indication (30/39, 77%) for TFA was periprosthetic joint infection (PJI) or fracture-related infection (FRI); and 23/39 (59%) had a prior periprosthetic fracture (PPF). TFA was performed with dual-mobility or constrained cups in 31/39 (79%) patients. Within the cohort, 12 TFAs (31%) required subsequent revision surgery: infection (7 TFAs, 18%) and instability (5 TFAs, 13%) were the most common indications. 90% of patients were ambulatory post-TFA; 2 patients required disarticulation due to recurrent PJI. While 31/39 (79%) were infection free at last follow-up, the remainder required long-term suppressive antibiotics. This is the largest series of TFA for non-oncological indications. Though TFA has inherent risks of instability and infection, most patients are ambulant after surgery. Patients should be counselled on the risk of life-long antibiotics, or disarticulation when TFA fails

Aim. Repeat revision surgery of total hip or knee replacement may lead to massive bone loss of the femur. If these defects exceed a critical amount a stable fixation of a proximal or distal femur replacement may not be possible. In these extraordinary cases a total femur replacement (TFR) may be used as an option for limb salvage. In this retrospective study we examined complications, revision free survival (RFS), amputation free survival (AFS) and risk factors for decreased RFS and AFS following a TRF in cases of revision arthroplasty with a special focus on periprosthetic joint infection (PJI). Method. We included all implantations of a TFR in revision surgery from 2006–2018. Patients with a primary implantation of a TFR for oncological indications were not included. Complications were classified using the Henderson Classification. Primary endpoints were revision of the TFR or disarticulation of the hip. The minimum follow up was 24 month. RFS and AFS were analyzed using Kaplan-Meier method, patients´ medical history was analyzed for possible risk factors for decreased RFS and AFS. Results. After applying the inclusion criteria 58 cases of a TFR in revision surgery were included with a median follow-up of 48.5 month. The median age at surgery was 68 years and the median amount of prior surgeries was 3. A soft tissue failure (Henderson Type I) appeared in 16 cases (28%) of which 13 (22%) needed revision surgery. A PJI of the TFR (Henderson Type IV) appeared in 32 cases (55%) resulting in 18 (31%) removals of the TFR and implantation of a total femur spacer. Disarticulation of the hip following a therapy resistant PJI was performed in 17 cases (29%). The overall 2-year RFS was 36% (95% confidence interval(CI) 24–48%). Patients with a Body mass Index (BMI) >30kg/m² had a decreased RFS after 24 month (>30kg/m² 11% (95%CI 0–25%) vs. <30kg/m² 50% (95%CI 34–66%)p<0.01). The overall AFS after 5 years was 68% (95%CI 54–83%). A PJI of the TFR and a BMI >30kg/m² was significantly correlated with a lower 5-year AFS (PJI 46% (95%CI 27–66%) vs no PJI 100%p<0.001) (BMI >30kg/m² 30% (95% KI 3–57%) vs. <30km/m² 85% (95% KI 73–98%)p<0.01). Conclusions. A TFR in revision arthroplasty is a valuable option for limb salvage but complications in need of further revision surgery are common. Patients with a BMI >30kg/m² should be informed regarding the increased risk for revision surgery and loss of extremity before operation

Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

This work examines the Upper limb (UL) blast-mediated traumatic amputation (TA) significance from recent operations in Afghanistan. It is hypothesized that the presence of an UL amputation at any level is an independent predictor of torso injury. A joint theatre trauma registry search was performed to determine the number of British casualties with TA and their associated injuries. UL TA accounted for 15.7% of all amputations; distributed: shoulder disarticulation 2.5%, trans-humeral 30%, elbow disarticulation 10%, trans-radial 20% and hand 37.5%. The presence of an UL amputation was more likely in dismounted casualties (P=0.015) and is a predictor of an increased number of total body regions injured and thoracic injuries (P 0.001 and P 0.026 respectively). An increased Injury Severity Score (ISS) was seen in patients with multiple amputations involving the UL (UL TA present ISS=30, no UL TA ISS=21; P=0.000) and the ISS was not significantly different whether mounted or dismounted (P=0.806). The presence of an upper limb amputation at any level should insight in the receiving clinician a high index of suspicion of concomitant internal injury; especially thoracic injury. Therefore with regards to blast mediated TA the injury patterns observed reflect a primary and tertiary blast mechanism of injury

Background. Extendable proximal femoral replacements(PFR) are used in children with bone tumours in proximity to the proximal femoral physis, previously treated by hip disarticulation. Long-axis growth is preserved, allowing limb salvage. Since 1986, survival outcomes after limb salvage and amputation have been known to be equal. Method. Retrospective review of all patients <16years undergoing extendable PFR at Royal National Orthopaedic Hospital (UK) between 04/1996 and 01/2006, recording complications, failures, procedures undertaken and patient outcomes. Results. 8 patients (mean age 8.9±3 years) underwent extendable PFR for Ewing's Sarcoma(5), Osteosarcoma(1), Chondrosarcoma(1) and rhabdomyosarcoma(1). 2 primary PFRs failed (infection of unknown source & local recurrence, both at 26months); 2 required revision for full extension (1 became infected at revision, requiring 2 stage revision). 3 patients had the original prosthesis in situ at last follow-up (mean 7.2;range 3–10.5years). 1 patient had no implant complications, but died (neutropaenic sepsis) 63 days after implant insertion. 2 were treated for recurrence but disease free at last review. 5 were continuously disease free. 5 patients were lengthened a mean 3.7cm; 2 were not lengthened.1 had incomplete data. 5 patients suffered subluxation/dislocation (mean 15.6months), 3 recurrently. Each underwent a mean 1.6 open & 1.4 closed procedures for the displaced joint. 3 patients had 4 open reductions and acetabuloplasties and 2 patients were converted to THR, with 3 major complications: 2 sciatic nerve palsies and 1 (THR) infection. The 5th patient was due for acetabuloplasty but had hip disarticulation for recurrence. Acetabular erosion occurred in 3; 2 were revised to THR (3.5 & 6.8years). 3 patients suffered peri-prosthetic supracondylar fracture (treated conservatively). 5 patients were revised to THR (mean 5.9years): 2 for dislocation, 2 for acetabular erosion & 1 for infection. 1 underwent amputation and another died. Only 1 surviving implant was not converted to THR: this patient had progressive acetabular erosion at 10.5 years & will eventually require THR. The amputee had poor hip function prior to disarticulation but went on to become an international Paralympic sportsman and had very good function 11.4 years post-disarticulation. 3 patients had fixed hip adduction deformity. 1 was isolated and treated with adductor tenotomy, whilst 2 were associated with knee flexion deformity (one required in-patient physiotherapy; the other prosthetic shortening). Conclusions. Extendable PFR permits limb salvage with psychological & functional benefits, but complications are common and some are specific to PFR. Surgery for these may result in further complications. Patients should be warned of the high conversion rate to THR. All the above should be borne in mind when selecting patients. As illustrated above, functional outcome is sometimes better with amputation

Many pre-clinical models of atrophic non-union do not reflect the clinical scenario, some create a critical size defect, or involve cauterization of the tissue which is uncommonly seen in patients. Atrophic non-union is usually developed following high energy trauma leading to periosteal stripping. The most recent reliable model with these aspects involves creating a non-critical gap of 1mm with periosteal and endosteal stripping. However, this method uses an external fixator for fracture fixation, whereas intramedullary nailing is the standard fixation device for long bone fractures. OBJECTIVES. To establish a clinically relevant model of atrophic non-union using intramedullary nail and (1) ex vivo and in vivo validation and characterization of this model, (2) establishing a standardized method for leg positioning for a reliable x-ray imaging. Ex vivo evaluation: 40 rat's cadavers (adult male 5–6 months old), were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with an external fixator. Tibiae were harvested by leg disarticulation from the knee and ankle joints. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4) using Zwick/Roell® machine. Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. To maintain the non-critical gap, a spacer was inserted in the gap, the design was refined to minimize the effect on the healing surface area. In vivo evaluation was done to validate and characterize the model. Here, a 1 mm gap was created with periosteal and endosteal stripping to induce non-union. The fracture was then fixed by a hypodermic needle. A proper x-ray technique must show fibula in both views. Therefore, a leg holder was used to hold the knee and ankle joints in 90º flexion and the foot was placed in a perpendicular direction with the x-ray film. Lateral view was taken with the foot parallel to the x-ray film. Ex vivo: axial load stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices. Bending load to failure showed that 18G nails are significantly stronger than 20G, thus it is used for the in vivo experiments. In vivo: final iteration revealed 3/3 non-union, and in controls with the periosteum and endosteum intact but with the 1mm non-critical gap, it progressed to 3/3 union. X-ray positioning: A-P view in supine position, there was an unavoidable degree of external rotation in the lower limb, thus the lower part of the fibula appeared behind the tibia. To overcome this, a P-A view of the leg was performed with the body in prone rather, this arrangement allowed both upper and lower parts of the fibula to appear clearly in both views. We report a novel model of atrophic non-union, the surgical procedure is relatively simple and the model is reproducible

Introduction. We aimed to ascertain the oncological outcome of patients undergoing an amputation for sarcoma in our unit. Method. A retrospective analysis of patients undergoing amputation within a two-year period (2007-2009) was undertaken. Patients were identified from our sarcoma database and cross referenced with OPCS codes and HES data to ensure accuracy. A case note review was then undertaken. Results. 18 patients underwent an amputation over the two year period. There were 10 males and 8 females, mean age 55 (range 18 to 86). 5 amputations were upper extremity (2 forequarter, 2 shoulder disarticulation, and 1 below elbow) and 13 were lower extremity (1 hip disarticulation, 6 above knee, 4 below knee and 2 toe). The diagnosis was confirmed sarcoma prior to amputation. 14 were performed with curative intent, 4 palliative. Each case was discussed at the sarcoma MDT prior to surgery. One patient had induction chemotherapy and two patients pre-operative radiotherapy in an attempt to reduce the size of tumour. 4 patients had undergone surgery outside our sarcoma service prior to referral - in 3 cases limb salvage surgery was precluded by their treatment elsewhere. The median length of stay was 9 days (range 0-165). 7 patients have died of disease and one further patient has metastatic disease. Conclusions. The length of stay in patients undergoing amputation is short by comparison to other groups of patients. Those patients requiring amputation for sarcoma have a poor prognosis. In the relatively short follow up of patients in this group 39% (7 of 18) have died of disease. This may be due to the size of the tumour, the aggressiveness of the tumour or other factors that are unexplainable

Introduction: Total femoral endoprosthetic replacement can be used as an alternative to hip disarticulation following extensive tumour excision or in cases of more severe bone loss. To date there have been no long term studies on the oncological and functional outcome of patients who have had this procedure for malignant bone disease. We report our experience of over 25 years employing this procedure using a custom-made and modular total femoral endoprosthetic replacement. Methods: This is a retrospective, single centre study of 27 patients who underwent consecutive total femoral replacement as a primary procedure between 1978 and 2005. Information was collected from the bone tumour database, medical records and clinic review. Outcome was assessed using the Musculoskeletal Tumour Society (MSTS) rating score, the Harris Hip Score (HHS) and the Oxford Knee Score (OKS). Results: There were 15 males and 12 females, with a mean age of 30 years (5 to 65). The overall mean follow-up was 4.3 years (1 to 16.4) for all patients, 9.1 years (1 to 16.4) for the 7 patients who were alive at the time of this review, and 2.6 years (1 to 13) for the 20 patients who had died. 24 patients had primary malignant bone tumours of the femur and 3 had metastatic disease from a known primary elsewhere. 3 patients developed local recurrence, 1 patient developed new lung metastases. Mean MSTS score was 63% (19/30), mean HHS was 68/100 and mean OKS was 34/48. Discussion: Total femoral replacement can be an effective alternative to hip disarticulation in patients with malignant bone disease. Good functional outcomes can be achieved without compromising survival

There is a growing trend towards using pre-clinical models of atrophic non-union. This study investigated different fixation devices, by comparing the mechanical stability at the fracture site of tibia bone fixed by either intramedullary nail, compression plate or external fixator. 40 tibias from adult male Wistar rats' cadavers were osteotomised at the mid-shaft and a gap of 1 mm was created and maintained at the fracture site to simulate criteria of atrophic non-union model. These were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with external fixator. Tibia was harvested by leg disarticulation from the knee and ankle joints, the soft tissues were carefully removed from the leg, and tibias were kept hydrated throughout the experiment. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4). Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. Axial load to failure data and stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices, however there was no statistically significant difference axially between the nail thicknesses. In bending, load to failure revealed that 18G nails are significantly stronger than 20G. We concluded that 18G nail is superior to the other fixation devices, therefore it has been used for in-vivo experiments to create a novel model of atrophic non-union with stable fixation

Purpose: The purpose of this work was to analyse survival and prognostic factors in a series of patients treated for pelvic chondrosarcoma. Material and methods: This series included 67 patients (27 women and 40 men) treated between 1971 and 1996 for pelvic chondrosarcoma. Mean age at diagnosis was 45 years (range 18–78). Forty percent of the tumours were grade I. The most frequent localisation was the iliac bone. Conservative surgery was performed in 45 patients. The only surgical treatment possible in 22 patients was an inter-ilioabdominal disarticulation. Resection margins were adequate for only 19 patients (wide resection). Marginal resection was noted in 14 patients with intra-tumour resection in 17. Results: Overall 5- and 8-year survival was 65% and 58% respectively. Local recurrence rate was 40%, occurring a mean 27 months after initial surgery. Statistical analysis did not reveal any correlation between tumour size, tumour grade, type of surgery, resection margin, and local recurrence. Results were nevertheless less favourable in case of inadequate surgical margins. Tumour grade, tumour size, patient age, gender, and quality of resection did not have a significant effect on overall survival. Local recurrence was the only negative factor predictive of survival (p< 0.05). Discussion: Development of local recurrence appears to be the most important negative predictive factor in patients with pelvic chondrosarcoma. In this localisation, satisfactory resection margins are often difficult to achieve. Most authors propose inter-ilioabdominal disarticulation as a last resort procedure. The question of the indication for more aggressive initial surgery to obtain more radical resection margins remains open

There is a growing trend towards using pre-clinical models of atrophic non-union. This study investigated different fixation devices, by comparing the mechanical stability at the fracture site of tibia bone fixed by either intramedullary nail, compression plate or external fixator. 40 tibias from adult male Wistar rats' cadavers were osteotomised at the mid-shaft and a gap of 1 mm was created and maintained at the fracture site to simulate criteria of atrophic non-union model. These were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with external fixator. Tibia was harvested by leg disarticulation from the knee and ankle joints, the soft tissues were carefully removed from the leg, and tibias were kept hydrated throughout the experiment. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4). Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. Axial load to failure data and stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices, however there was no statistically significant difference axially between the nail thicknesses. In bending, load to failure revealed that 18G nails are significantly stronger than 20G. We concluded that 18G nail is superior to the other fixation devices, therefore it has been used for in-vivo experiments to create a novel model of atrophic non-union with stable fixation

The authors review the currently available treatments according to analysis of the literature. In the event of prosthetic infection, protocols available at the moment are: specific antibiotic therapy without débridement, débridement with conservation of the prosthesis, one-stage replacement of the prosthesis, débridement with definitive prosthesis removal, arthrodesis,amputation or disarticulation. The choice of the treatment must be based on the analysis of local and general factors: type of infection, clinical presentation, quality of soft tissues, prosthetic implant condition, pathogens involved, function of the knee extensor mechanisms and patient’s expectations and functional requirements. We re-evaluated the literature reports. Antibiotic therapy in infected hip prostheses yielded a successful outcome in 64% of the cases. Arthrotomic débridement in total hip prostheses showed a successful outcome in a variable percentage from 74% to 14%; in contrast, arthroscopic débridement showed a successful outcome in 100% of cases. In total knee replacement the arthrotomic débridement showed a success rate of 32.6% and arthroscopic débridement 52.2%. The mean percentage of success in replacement in one stage with antibiotic cement and preoperative antibiotic therapy was 82% in THA [1], and 71% in TKA [6]. The mean percentage of success in replacement in two stages with spacer cement and perioperative antibiotic therapy was more than 90% in THA and 91% in TKA. Prosthesis replacement in two stages showed the best rate of positive results. The antibiotic therapy was effective in all patients with positive cultures intraoperatively. Arthrotomic or arthroscopic débridement is a valid procedure, but must be performed within 2 weeks from the appearance of the symptoms. Knee arthrodesis is preferable in the presence of pathogens resistant to antibiotics and is indicated in patients with high functional requirements. The Girdlestone arthroplasty is indicated in hip treatment when antibiotic-resistant pathogens are involved. Amputation and disarticulation are indicated only in patients with a poor survival prognosis. The management of prosthetic infections represents a challenge to the entire multi-disciplinary team (i.e. specialists in microbiology, radiology, infectious diseases and orthopaedics) both in achieving a correct diagnosis (infection versus aseptic loosening) and in choosing an adequate therapeutic strategy

Introduction and Aims: Orthopaedic oncologists are often consulted regarding problems involving salvage of the distal femur due to bone loss, non-unions, infections. In young patients, extensive bony reconstruction is often necessary; in elderly, low demand patients, replacement with an endoprosthetic device results in decreased surgical time and more rapid mobilisation. Method: Since 1991, 27 patients underwent reconstruction with a custom modular distal femoral replacement and rotating hinged knee joint (DFR). Twenty-two (81%) were revised to a DFR from an existing knee arthroplasty. Diagnoses included fracture, non-union, osteomyelitis, osteolysis or deformity. Average age was 66 (25–85); 83% were female. Most patients had undergone multiple prior surgeries. Patients with a history of infection had undergone aggressive resection and insertion of spacers with prolonged antibiotic administration, however they had no infection at the time of DFR reconstruction. All endoprostheses were cemented. Patients were allowed immediate weight-bearing and rehabilitation similar to patients undergoing TKA. Results: One elderly patient died in the immediate peri-operative period of respiratory failure and one was lost to follow-up after placement in a nursing home. Average follow-up on 25 evaluable patients was 47 months (7–122). Reoperations were for recurrent infection (six) and tibial component loosening (three). Five of the six with infection were treated with synovectomy, antibiotic beads and suppressive oral antibiotics, and all five devices are still in place at an average of 54 months (range, 25–100). One severely diabetic patient had had multiple episodes of sepsis unrelated to the prosthesis which eventually seeded the distal femur and required a hip disarticulation. MSTS functional scores at last follow-up averaged 49% (13–80%) and HSS knee scores averaged 71% (37–90%). Conclusion: DFR is a useful salvage procedure in low demand patients. Initially, six patients were scheduled for transfemoral amputation and three were confined to wheelchairs. Patients other than the hip disarticulation were at minimum household ambulators at last follow-up. In spite of problems with infection, most patients improved in overall function

Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms. All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams. 36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality. Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes

Aims

Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications.

Aims

Research on hip biomechanics has analyzed femoroacetabular contact pressures and forces in distinct hip conditions, with different procedures, and used diverse loading and testing conditions. The aim of this scoping review was to identify and summarize the available evidence in the literature for hip contact pressures and force in cadaver and in vivo studies, and how joint loading, labral status, and femoral and acetabular morphology can affect these biomechanical parameters.