Introduction: Two stage revision procedures is the gold standard in management of periprosthetic infections. Cement spacers impregnated with antibiotics have long been used to preserve the space created during resection procedure and to release antiobiotics within the created dead space. However, the problems related to cement as an antibiotic carrier are well recognised (random porosity, thermal necrosis, unspecified antibiotic delivery rate). The rationale of this study is that calcium hydroxyapatite antibiotic carrier (PerOssal) overlaps the known disadvantages of cement spacers, and leads to better outcome in terms of clinical parameters and re-infection rate.

Purpose: Our purpose was to identify specific clinical and laboratory differences between cases submitted to conventional two stage revision arthroplasty vs cases treated with PerOssal as an antibiotic carrier.

Material & Methods: During 2004 to 2008, 46 patients (38 females and 8 males, mean age 65.3 years, range 32 to 84) with infected TKR were revised using a two-stage revision protocol. In 31 patients (group A – 25 females and 6 males) a conventional articulating spacer impregnated with antibiotics was used, whereas in the remaining 15 patients (group B – 13 females, 2 males) a combination of an articulating spacer and PerOssal as antibiotic carrier was used. All patients were reviewed with laboratory exams (WBC, ESR, CRP) every 7 days and joint fluid aspiration prior to re-implantation, which was performed at mean 8 months post 1st stage (range, 6 to 12 months).

Results: At a mean follow-up of 36 months (range, 8 to 60 months) no patient was lost or died. WBC count and ESR showed no statistically significant differences at any time interval (p> 0.05). However, CRP values had a statistically significant difference between the two groups after the second week postoperatively (p3rd week= 0.042) and group B had significantly lower CRP values compared to group A at every check point thereafter (p4th week=0.038, p5th week=0.031, p6th week=0.034). Re-infection rate was 16.12% in group A and 6.6% in group B (p=0.192).

Conclusions: PerOssal can be used as an additional antibiotic carrier in cases of periprosthetic infections of TKR. It is associated with more rapid reduction of CRP levels, probably due to greater porosity and better antibiotic delivery comparing to impregnated cement. Larger series of patients could reveal potential differences in the re-infection rates as indicated by our study.

Background: We present our further experience with the Orthofix tibial nailing system, concurrently evaluating the easy and safety of the distal targeting system for the distal locking.

Materials & Methods: Ninety-seven fresh tibial fractures in the same number of patients with a mean age of 38,5 years (17–85) were treated. Three were lost from the follow-up. Twenty of the fractures were grade I open fractures, four grade II and one grade IHA. All operations were performed in a conventional operating theater on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site, hi most of the cases closed reduction was achieved and conventional reaming performed; in 14 patients the fracture was reduced through a small incision at the fracture site. Conventional reaming (power reaming) was performed in 69% of the patients; however, in 31% of the cases (30 patients), only minimal hand reaming was performed. The mean duration of the operation was 30 min. The external targeting device failed in 10 distal locking screws, in six of which the second attempt was successful. In four an image intensifier had to be used.

Results: Fracture healing, confirmed clinically and radiographically, was observed at a mean of 17 weeks (12–28 weeks). No tibial non-union necessitating reoperation occurred, however six fractures showed delayed union. Open reduction didn’t compromise the healing of the fracture. All patients eventually gained a full range of motion knee and ankle joint and only twelve of them (12%) complained of mild anterior knee pain. All patients returned to their previous activity, except for one disabled from a head injury. The later evaluation showed preservation of the tibial axis in all patients and additionally that no mechanical failure of either the nail or the screws occurred.

Conclusions: We conclude that the Orthofix nailing system is a clinically effective system. Distal locking can be performed with ease without significant exposure to radiation, provided that the operative technique is accurately followed, the nail is inserted without significant force and the distal targeting device is not subjected to any violation, such as hammering.