Aim & introduction

Infected knee with bone defect resulting from failed total knee arthroplasty (TKA) or destruction of native joint can necessitate restoration of segmental defect and arthrodesis for therapy of infection and maintenance of walking ability. In segmental knee defect external fixators or KAFO are not suitable, not comfortable and poor tolerated by elderly patients. Both custom-made Femoro-Tibial Nail (FTN) combined with acrylic cement spacer and Knee Arthrodesis Nail System (KANS) offer maintenance of supportive function of extremity and avoidance of leg length discrepance after removal of TKA.

The aim of the study was to determine the effectiveness and complications of hinged TKA revisions and the results of periprosthetic joint infection (PJI) treatment in such cases.

We have retrospectively reviewed 14 hinged TKA (Orthopedic Solution System, OSS, Biomet) in 14 patients. The patient average age was 70 years (range 56 to 83). The indication for the hinged TKA was: implant loosening (4 cases), periprosthetic fracture (3 cases), TKA instability (1 case) revision after spacer removal (1 case), advanced knee instability during primary TKA (3 cases), pseudoarthrosis due to previous tibial osteotomy (1 case) and tumor resection of the distal femur (1 case). The mean follow up was 26 months (range 6 to 60).

There have been 8 revisions in six patients. The indications for revision have been: infection (5 cases), skin necrosis (1 case), flexion contracture (1 case), and patellar luxation with extensor mechanism rupture (1 case). No aseptic loosening has been noted. In septic cases debridement was performed in 4 knees (debridement, antibiotics, implant retention, DAIR) and in one case two-stage revision with spacer. The average time from hinged TKA to revision due to any of the reasons was 13 months (range 2 to 41 months) and in case of septic revision 17 months (range 2 to 41). The mean follow up after septic revision was 30 months (range 24 to 41). In all the cases infection has healed. All the patients have been satisfied with the procedure and reported significant increase in the quality of life (mean HSS score 85). The mean pain score (NRS) has decreased from 7 preoperatively to 1. All the patients have reached at least 90 degrees of knee flexion.

The revisions of large implants are both demanding and expensive. In 4 of 5 cases DAIR has been successful in the treatment of PJI even though performed over the recommended time. The authors believe it could be considered in some PJI cases when implant removal is not an option.

The aim of the study is to determine reimbursement cost of treating periprosthetic joint infection (PJI) in Poland, the rate of THR and TKA septisc revisions in the years 2009–2013, the type of revision, comparison of the costs of septic and aseptic revisions.

Data published on the website of the National Health Fund (NHF) were analysed on revision arthroplasty for aseptic and septic recisions in the years 2009–2013. To calculate the cost of revision NHF report for 2013 was analysed giving the average cost of the group of septic and aseptic revision.

According to NHF „point system”, in therapy of PJI three types of revisions can by choosen: partial revision (305 points), one-stage revision (490 points), and two-stage revision with spacer (728 points for two stages). In the years 2009–2013 a total of 260030 THR and TKA were performer, including 23027 revisions. There were 4221 septic revisions: 1677 hips and 1430 knees. In 2013 septic revisions stated 1.38% (556 of 40152) of all hip and 2.56% (325 of 12654) of all knee replacements. Septic revisions constituted 14.67% of all hip revisions and 30.23% of all knee revisions. The average refund of the NHF for a minor revision for PJI in 2013 was 3889 Euro and the average cost for hospital was 4127 Euro. The average refund of the NHF for a one-stege revision (for any reason) in 2013 was 6124 Euro, and the average cost for hospital was 6339 Euro. The average refund of the NHF for a two-stage revision (for two stages) in 2013 was 10013 Euro, and the average cost for hospital was 10466 Euro for two hospital stays. Data revealed that in 2013 all 921 revisions performed for PJI were reimbursed as „minor revisions” for 3889 Euro. In 2013 the difference between the average cost incurred by the hospital and the refund of the NHF for septic revision was at least 238 Euro and for the entire year undervalued refund for treatment of 921 infected prostheses was at least 219198 Euros.

The reimbursement for revision due to infection encourages surgeons to perform two-stage septic revision instead of debridement or one-step, because two-step treatment in the final bill is better paid.

Infected nonunion of the femur or tibia diaphysis requires resection of infected bone, stabilization of bone and reconstruction of bone defect. External fixation of the femur is poorly tolerated by patients. In 2004 authors introduced in therapy for infected nonunions of tibia and femur diaphysis coating of IMN with a layer of antibiotic loaded acrylic cement (ALAC) containing 5% of culture specific antibiotic.

Seven patients with infected nonunion of the diaphysis of femur (2) and tibia (2) were treated, aged 20–63 years, followed for 2–9 years (average 5,5 years). All have been infected with S. aureus (MSSA: 2 and MRSA: 4) or Staph. epidermidis (1) and in one case with MRSA and Pseudomonas aeruginosa. All patients underwent 3 to 6 operations before authors IMN application. Custom-made IMN coated with acrylic cement (Palamed) loaded fabrically with gentamycin with admixture of 5% of culture-specific antibiotic: vancomycin (7 cases) and meropeneme (1 case) was used for bone stabilization. Static interlocking of IMN was applied in 4 cases and dynamic in 2 cases. In 1 case the femur was stabilized with IMN without interlocking screws. In 2 cases IMN was used for fixation of nonunion at docking site after bone transport. In 3 cases ALAC was used as temporary defect filling and dead space management. In one case after removal of IMN coated with ALAC, a new custom made Gamma nail and tubular bone allograft ranging 11 cm was used for defect reconstruction.

Infection healing was achieved in all 7 cases, bone union was achieved in 4 from 7 cases. In 1 case of segmental diaphyseal defect ranging over 12 cm infection was healed, but bone defect was not reconstructed. This patient is waiting for total femoral replacement. In another case of segmental defect of 11 cm infection is healed, but allograft substitution and remodeling by host bone is poor. In the 3rd case of lacking bone healing, the 63 year old patients was noncooperative and not willing to walk in walker with weight bearing. This patient refused further treatment.

Custom-made intramedullary nail coated with a layer of acrylic cement loaded with 5% of culture specific antibiotic can provide local infection control, offer comfortable bone stabilization, and replace standard IM nail in therapy for difficult to treat infected diaphyseal nonunion of femur or tibia.

The aim of the study is to evaluate the effect of acrylic cement CMW1 (DePuy) containing 2,5% of gentamicin and addition of 5 % and 10 % of respective vancomycin, meropeneme and ceftriaxone on growth inhibition of reference strains of MRSA, E. faecalis, S. aureus, P. aeruginosa and E. coli.

From every portion of investigated acrylic cement CMW1 discs were cut with a diameter of 15mm and a thickness of 5mm, average weight 1.365 g (+/− 0,257g). Inoculum was prepared with the reference strains: MR3 S. aureus methicillin-resistant (MRSA), ATCC 29219 E. faecalis, ATCC 25923 S. ureus, ATCC 27853 P. aeruginosa and ATCC 25922 E. coli. A colonies of bacteria taken from a 18-hour culture on solid medium were addend to tubes with sterile physiological saline solution to obtain a density of 0.5 McFarland (5 × 105 CFU / ml). The suspension was distributed evenly over the Mueller-Hinton (MH) medium (Biomerieux, France). Prepared discs of CMW1 cement were put with a sterile forceps on the plate with a dry medium. The plates were incubated aerobically at 24 hr and the temp. 37°C.

After 24 hours the diameter of zone of inhibition of bacterial growth on a plate was measured (in mm) and average size of the inhibition zone was calculated. The CMW1 cement inhibited to a comparable degree growth of reference strains with the exception of E. faecalis. The addition of vancomycin increased by 1/5 inhibitory potential of CMW1 cement on growth of MRSA, S. aureus, P. aeruginosa and E. coli. and significantly for E. faecalis. Changing the concentration of vancomycin, meropeneme and ceftriaxone from 5% to 10% do not increased the inhibitory potential of CMW1 cement on the growth of MRSA, S. aureus, P. aeruginosa, E. coli and E. faecalis. Addition of meropeneme increased inhibitory potential of CMW1 cement against MRSA by 1/3, P. aeruginosa and E. coli by ½, E. faecalis by 3/4 and against S. aureus by 100%. Addition of ceftriaxone to CMW1 cement increased the inhibiting of the growth of MRSA similiarly to 5% and 10% of vancomycin, E. faecalis as meropeneme 5% and 10 %, while the growth of S. aureus and P. aeruginosa, less than meropeneme.

Addition of antibiotics to acrylic cement increased its antibacterial properties. Increase if vancomycine concentrations from 5 to 10% had no stronger antibacterial effect.