Introduction: Prosthetic joint infections are a growing burden. Since we felt that we were far from the optimistic results recently published, we decided to find out the reality in our department. The goals were to determine:

The rate of infections in primary and revision surgery (hip and knee)

Materials and Methods: We retrospectively reviewed clinical records of all patients that underwent surgical treatment due to infected hip or knee prosthetic joint between 1st July 2001 and 31st December 2007.

Results: Since the majority of infections (67%) presented in the first two years after surgery, we determined the rate of infections taking in to consideration a minimum two years follow-up. We calculated a 1.8% (12/678) rate of infection for primary total hip and 3.3% (20/588) for primary total knee arthroplasty. There was no statistically significant difference between the two groups. Revision hip surgery had a 5.4% (15/243) infection rate and revision knee surgery revealed an even higher rate of 10.3% (4/42). The difference between primary and revision surgery was statistically significant both for hip and knee.

Considering an infection free arthroplasty as the goal, the overall success rate of treatment was under 48% (30/69). The success of treating infections with debridement and retention of components was even lower (29%). Further analysis revealed a higher success of this approach (45%) when considering more appropriate candidates (short term infections). An interesting statistically significant difference was found favoring this approach in the knee.

Two-stage revision strategy was successful in achieving revision arthroplasty in 43% (20/46) of the cases. Most patients were never considered candidates to the second stage procedure. Knee joint and resistant microorganisms were found to be predictors of bad prognosis.

There was a 90% (18/20) survival rate of revision arthroplasties after two years average follow-up. There were only 2 cases of relapsing infection both controlled without prosthetic removal.

Conclusion: Our results compare poorly with the latest published data from different centers. They led us to implement new prophylactic measures as well as review our diagnostic and treatment options.

Background: Braquial plexus injuries are a major indication for shoulder arthrodesis today. Numerous investigations have addressed the optimal position of the extremity for shoulder arthrodesis, and there are still numerous opinions on the ideal position. The present consensus appears to favor less abduction and forward flexion and more internal rotation.

Purposes: Our main goal is to determine the most favorable position for arthrodesis regarding upper limb function and prevalence of periscapular pain. Secondarily we describe the fusion and complications rate as well as patient satisfaction.

Materials and Methods: Between 1997 and 2008 the authors performed a total of 19 shoulder arthrodesis using a pelvic reconstruction plate in patients with braquial plexus injuries. Six were lost to follow-up leaving a total of 11 men and two women with a mean age of 46 years available for review. At a mean follow-up of 101 months [13–149] patients were evaluated clinically using predetermined functional parameters (hand-to-mouth, brachiothoracic grip, etc) and the visual analog pain scale. DASH score and radiological studies were also performed. Three patients that presented no active elbow flexion were excluded of the functional results analysis.

Results: The mean fusion position found was 20° abduction, 32° forward flexion and 44° internal rotation. Abduction ≥ 25° relates to better function as judged by a better hand-to-mouth and brachiothoracic grip ratio as well as a better DASH score (38.8 vs. 45.4) but is also unfortunately related to higher periscapular pain prevalence (VAS pain 3.75 vs. 1.38). Forward flexion ≤ 30° also relates to slightly higher periscapular pain prevalence (VAS pain 2.7 vs. 1.7) and a better DASH score (39.5 vs. 47.7). Exaggerated internal rotation seems to have a negative influence on the functional outcome. Although relating to a surprisingly better DASH score (39.7 vs. 44.9), none of the three patients presenting with internal rotation over 45° was able to reach the mouth with his/her hand. Fusion was obtained in 12 patients. Major complications included one pseudarthrosis, one malpositioning of the extremity that forced a revision surgery to increase internal rotation and one humeral shaft fracture treated conservatively. All but one patient (including those with no active elbow flexion) were satisfied/very satisfied with the final outcome.

Discussion: Our results suggest abduction around 25° and forward flexion of no more than 30° are needed. Higher abduction and lower forward flexion values although relating to better function do so at the expense of more periscapular pain. We agree with the present trend towards increasing internal rotation but found that it should not exceed 45°.

Aims: A previous study demonstrated that negative pressure wound therapy (NPWT) increases tissue pressure. This conflicts with the understanding that these dressings increase perfusion. This randomised case control study investigates the effects that circumferential NPWT has on perfusion in humans and how different suction pressures influence this.

Methods: Ten healthy volunteers were recruited into the study and sequentially randomised to receive suction pressures of either −400 mmHg or −125 mmHg. With both hands placed in circumferential NPWT dressings, suction was only applied to one hand. Perfusion of both hands was then analysed simultaneously using radioisotope perfusion imaging. After allowing one week for complete excretion and decay of the isotope, an identical experiment was done on the same volunteers’, this time using the contralateral hand as the test hand. A total of 20 scans were carried out. Data were analysed using the Wilcoxon and Mann-Whitney tests.

Results: In the hands that received suction pressures of −400 mmHg, there was a highly significant mean reduction in perfusion of 40% (SD 11.5%, p< 0.0005). In the hands that received suction pressures of −125 mmHg there was also a highly significant mean reduction in perfusion (mean 17%, SD 8.9%, p< 0.0005). The reduction in perfusion of the group undergoing NPWT at −400 mmHg was significantly greater than the group undergoing NPWT at −125 mmHg (p< 0.015).

Conclusion: Tissue perfusion beneath circumferential NPWT dressings is significantly reduced when suction is applied, regardless of whether suction pressures of −125 mmHg or −400 mmHg are utilised. There is a significantly greater reduction in perfusion at suction pressures of −400 mmHg, compared to −125 mmHg. This implies that circumferential NPWT should be used with extreme caution, if at all, on tissues with compromised perfusion. This finding represents a paradigm shift in our understanding of the mechanism of action of NPWT.

Chondrosarcoma is the second most frequent primary malignant tumour of bone, representing approximately 25% of all primary osseous neoplasms. Chondrosarcomas are a group of tumours with highly diverse features and behavior patterns, ranging from slow-growing non-metastasizing lesions to highly aggressive metastasizing sarcomas. As radio and quimio-resistant tumours, the surgery constitutes the unique chance of cure. Nowadays, besides the curative intention, the reconstructive surgery is also a priority in order to save the limb and optimize the function.

This case report is about a young woman, of 24 years old, with hip-related pain and a large mass in the left pelvis. The imagiologic study showed a large mass of about 8 cm of large diameter, starting at the anterior wall of the acetabulum, involving the pubic arcs and with matrix calcification. The core needle biopsy confirmed the presence of a chondrosarcoma, staged as a IIB of Enneking.

Because of its size and localization the limb salvage surgery has been a challenge. The surgery included a broad approach of the left hemipelvis, with wide excision of the tumour, reconstruction of the abdominal wall with a propylene prothesis and reconstruction of the hemipelvis with a “custom-made” prothesis with preservation of the femoral neurovascular bundle. The patient started to walk with total bearing after three months and had a normal gait and a nearly normal life during eleven months. Fifteen months after the surgery lung metastasis and local recurrence were diagnosed and she died six months after.

Conclusion: The surgery is our unique weapon in the “combat” against the chondrosarcoma. The reconstructive surgery must be a concern to give to our patients the best functional result and quality of life.