Introduction: Failed total knee replacement due to the daemage of bone stock and infection requires removal of prosthesis. Successful arthrodesis is strongly related to the quality of bone stock. Both external fixators and KAFO are not comfortable and thus poor tolerated by elderly patients. Instable knee is very disabling condition. Custom-made femoro-tibial nail combined with acrylic cement spacer offers maintenance of supportive function of extremity after removal of knee prosthesis. Avoidance of leg length discrepance is possible. Nailing can be considered only as salvage procedure for one knee.

Material and Method: Six elderly patients underwent unilateral arthrodesis of the knee after removal of knee prosthesis due to the daemage to the bone stock and periprosthetic infection. They have had conical shape of the lower leg and poor quality to the bone. Thus they were not suitable for conventional knee arthrodesis using external fixator or for pseudoarthrosis and KAFO. After removal of TKR and debridement of periprosthetic tissues an ortograde, custom-made femoro-tibial interlocking nail was inserted. The gap betveen distal femur and proximal tibia was filled with hand-made acrylic cement spacer loaded with vancomycin (2g per 40 g cement) so that the spacer finally gained tubular shape.

Results: No recurrence of infection was noted. Early postoperative full-weight bearing was possible. Implant failure occurred in one case and required replacement of nail and cement spacer. Stress fracture of femoral neck occurred in another case. Despite of this problems all patients has better ADL than with KAFO or after

Conclusion: femoro-tibial nail for failed TKR is good accepted and comfortable for patient. Disadvantage of this type of nail is stiff knee and risk for nail fracture.

Infections regularly complicate orthopaedic procedures loosing implant stability and impairing bone union. Nevertheless, the question whether infection is caused by pathogens transposed intraoperatively, infiltrating the implant with blood stream or lymph, or dwelling in clinically healthy tissues, remains unanswered. The AIM of our study was to validate the hypothesis that pathogens may residue deep tissue.

Material and Methods: Skin, subcutaneous fat, muscle and fracture gap callus were obtained from 155 adult patients operated on due to closed comminuted fractures of tibia or femur, 75 because of non-alignment of bone axis and 80 due to delayed fracture healing.

Results: Aerobic bacteria were isolated from gap callus of 12% healing and 31% non-healing fractures, but also from deep soft tissues. No anaerobic bacteria were detected. PCR amplifications of 16s rRNA were found positive in 40% of callus specimens proving presence of bacterial DNA even when no isolates were found. The 95% similarity of the genetic pattern of some strains from foot skin and callus, estimated with RAPD technique, suggested their foot skin origin.

Conclusions: The colonizing bacteria and their DNA were detected in fracture callus and deep soft tissues. Contamination was precluded by lack of isolates in disinfected skin and materials used for sampling cultured after surgery. Our results point out that bacterial cells residing clinically non-infected deep tissues may be a source of infection, when activated by mechanical trauma and/or orthopaedic implant insertion.

Introduction: The study is aimed to present patient oriented diagnostics, treatment, remote rehabilitation potential and preliminary outcomes assessment in the group of osteoporotic compression fracture cases.

Methods: 3D postural assessment originally developed of spinal curvatures, semi quantitative radiographic evaluation and QCT BMD measurement were used in the study. The kyphosis angle based on back shape curve was measured on the 3D surface image utilizing dedicated software mimicking Debrunner kyphometer measurement. Radiographic assessment and measurements were performed on digital images using DICOM viewing analytic software (DICOM Vision, Alteris Ltd.). Radiographic assessment of VCF was based on semiquantitative visual and quantitative morphometric assessment. Bone mineral density were measured utilizing DXA BMD (g/cm2) and QCT BMD (mg/cm3) of the lumbar spine. The polish translation of Oswestry Disability Index (ODI) version 2.1a (http://www.orthosurg.org.uk/odi/index.htm). Telerehabilitation service was served as a supplementary service utilizing Internet videoconferencing. Summary and nonparametric statistical analysis was performed.

Results: The group of elderly patients finally enrolled to the study consisted of patients whose data, images, and other examinations were analyzed. Average age of patients was 73,22 years. Average number of fractured vertebra was 3,6 in the study group. The most frequent anatomical location of fractures was lumbar first and third vertebral body. The most frequent fracture types according to Genant et al. classification were Biconcave Grade II (38,6%) and Wedge Grade II (36,9%). The most frequent 53-A1.2 and 53-A2.1 types of fractures. An average QCT bone density was lower than 80 mg/cm3 in whole examined group that represents severe osteoporosis. Bone density lower than 30 mg/cm3 was found in almost one third of the group that coincided with highest number of fractured vertebral bodies. Oswestry disability score was highest along with lowest values of QCT BMD, and significantly improved after vertebral augmentation. Telerehabilitation was considered as successful among computer skilled patients.

Discussion: and Conclusion: Described personalized approach shows the flow of the individual patient from Metabolic Bone Diseases and Osteoporosis Unit through diagnostics and surgery to telerehabilitation service opportunities. The 3D structural light method of posture was developed and implemented. Telerehabilitation service may activate patients at home. Complex personalized, team approach to osteoporotic vertebral fractures consisted of new diagnostics, vertebral augmentation and remote rehabilitation.

We previously reported the presence of the bacterial genetic material (16S rRNA) and viable pathogens in fracture gaps specimens, which suggests an impaired pathogen recognition and/or elimination. The aim of study was to validate the hypothesis that patients with delayed bone fracture healing express the higher frequency of TLR4 mutations. Observations were performed in 295 patients treated due to closed fractures of the long bones of the lower extremity; in 151 with delayed bone union (Group A), and in 144 with uneventful healing (Group B). Control group consisted of 125 healthy blood donors from ethnically the same as investigations groups polish population. Fracture gaps and deep tissue biopsies served for microbiological studies, and DNA isolated from venous blood leukocytes was used for analysis of mutations of TLR4 gene at Asp299Gly (1/W) and Thr399Ile (2/W).

Results: Microbiological studies revealed positive isolates in 31.5% fracture gaps in Group A and 16.4% in Group B (p< 0.05). The most frequent isolates were S. epidermidis, S. aureus and S. warneri, capitis, sciuri and lentus, in lower percentage micrococci and enterococci. Amplification of 16S rRNA was positive in 56.8 and 65.2% of fracture gaps in both groups respectively. The frequency of occurrence of 1/W was significantly higher (p< 0.05) in subgroups of patients with non-healing infected vs. sterile fractures. In all subgroups with viable pathogens isolated from fracture gaps the frequency of 1/W allele was higher when compared with subgroups, where fracture gaps occurred sterile.

Discussion: Performed investigations supported our previously reported observations that gaps of closed bone fractures are not sterile and are positive for 16S rRNA. Genetic predisposal to infection and inflammatory response evoked by a single TLR4 mutation may be one of the factors affecting bone union. Observed coexistence of bacterial colonization with decreased inflammatory reaction observed in individuals bearing TLR4 mutations have to be mentioned as a possible, etiologic factor responsible for delayed healing