Aims

Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context.

Aims

Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition.

Aims

Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery.

Aims

We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

Aims

Pelvic reconstruction after the resection of a tumour around the acetabulum is a challenging procedure due to the complex anatomy and biomechanics. Several pelvic endoprostheses have been introduced, but the rates of complication remain high. Our aim was to review the use of a stemmed acetabular pedestal cup in the management of these patients.

Ankle replacements have improved significantly since the first reported attempt at resurfacing of the talar dome in 1962. We are now at a stage where ankle replacement offers a viable option in the treatment of end-stage ankle arthritis. As the procedure becomes more successful, it is important to reflect and review the current surgical outcomes. This allows us to guide our patients in the treatment of end-stage ankle arthritis. What is the better surgical treatment – arthrodesis or replacement?

Introduction:

To date, there have been few reports of the results of revisions for failed metal-on-metal hip arthroplasties (MoM HA's). These series have included relatively modest numbers, and classification of the severity of adverse local tissue reaction (ALTR) has been under-reported. In this study, early outcomes and complications are analyzed as a function of pre-operative MRI grade and intra-operative ALTR severity to determine their prognostic value.

Achieving arthrodesis of the ankle can be difficult in the presence of infection, deformity, poor soft tissues and bone loss. We present a series of 48 patients with complex ankle pathology, treated with the Ilizarov technique. Infection was present in 30 patients and 30 had significant deformity before surgery. Outcome was assessed clinically and with patient-reported outcome measures (Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and the Short-Form (SF-36)).

Arthrodesis was achieved in 40 patients with the Ilizarov technique alone and in six further patients with additional surgery. Infection was eradicated in all patients at a mean follow-up of 46.6 months (13 to 162). Successful arthrodesis was less likely in those with comorbidities and in tibiocalcaneal fusion compared with tibiotalar fusion.

These patients had poor general health scores compared with the normal population before surgery. The mean MAOFAS score improved significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to 90) post-operatively, but there was only a modest improvement in general health; the mean SF-36 improved from 44.8 (19 to 66) to 50.1 (21 to 76). There was a major benefit in terms of pain relief.

Arthrodesis using the Ilizarov technique is an effective treatment for complex ankle pathology, with good clinical outcomes and eradication of infection. However, even after successful arthrodesis general health scores remain limited.

Cite this article: Bone Joint J 2013;95-B:371–7.

Background. Salvage procedures on the 1st MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem. Methods. Between 2002 and 2009 our department performed 21, 1st MTPJ arthrodeses using a tri-cortical iliac crest interposition graft. Surgical fixation was achieved with a compact foot plate. We performed a retrospective review from the medical notes and radiographs along with American Foot and Ankle scores which were collected prospectively. We analysed the following parameters: time to radiological, requirement for further surgery, lengthening of 1st ray and any post operative complications. Results. Patient Demographics – Male: Female = 4:16. Mean age – 58 years (38-78 years). Mean follow up – 35 months (4-94 months). Indication for surgery –. Failed arthroplasty 8. Failed fusion 9. Previous Keller's 1. Failed Scarfe Osteotomy 1. Avascular Necrosis 2. Total 21. Arthrodesis achieved – 18 patients (90%) at 4 months post surgery (2-12 months). Mean AOFAS – 45 pre op, 75 post op. Lengthening of 1st Ray achieved – 6 mm average (5mm – 10mm). Complications – 7 (35%). Major – 3 (15%) – 2 non s, 1 varus overcorrection. Minor – 4 (20%) – 2 superficial infection, 2 painful hardware. Conclusions. Using interposition arthrodesis for the salvage of 1st MTPJ surgery we can achieve in 90% of patients. However, the rate of complications is not low and hardware often causes irritation, requiring removal

We present a series of 16 patients who have had a failed ankle arthroplasty converted to an ankle arthrodesis using a surgical technique of bone grafting with internal fixation. We describe our technique using tricortical autograft from the iliac crest to preserve length and an emphasis is placed on maintaining the malleoli and subtalar joint.

A successful fusion was achieved in all cases with few complications. Our post operative AOFAS improved to a mean of 70 with good patient satisfaction and compares well to other published series. From this series and an extensive review of the literature we have found fusion rates following failed arthroplasty in patients with degenerative arthritis to be very high. In this group of patients a high fusion rate and good clinical result can be achieved when the principles of this surgical technique are adhered to.

It would appear that a distinction should be made between treating patients with poor quality bone and more extensive bone loss, as is often the case with rheumatoid patients; and the patients with a non inflammatory arthropathy and better bone quality. The intramedullary nail would appear to be the preferred option in patients with inflammatory polyarthropathy where preservation of the subtalar joint is probably not of relevance as it is usually extensively involved in the disease process, and a higher rate of complications can be anticipated with internal fixation.

Introduction: ‘Revisability’ has been touted as one of the major advantages of resurfacing arthroplasty of the hip. However, this theoretical advantage has never been clearly demonstrated. The objective of the present study was to test the hypothesis that a failed, modern generation metal-on-metal resurfacing arthroplasty (MMRA) can be converted to a total hip (THA) as easily and with comparable results as a primary (THA).

Methods: Twenty-two failed MMRA’s in 21 patients with an average age of 49.5 years (23 – 72 years) were converted to a THA. In 18 hips, the acetabular component was retained, and in 4 hips both components were revised. The control group of primary THA’s, implanted during the same time period by the same surgeon, consisted of 64 patients with an average age of 50.8 years (27 – 64 years).

Results: There was no significant difference in operative time, blood loss and complication rates between the conversions and the controls. The average follow-up was 47 months (12 – 113 months) for the conversions and 57 months (24 – 105 months) for the controls. Clinical outcomes measures were comparable with average Harris Hip Scores of 92.7 and 90.3 for the MMRA conversions and primary THA’s, respectively. The UCLA activity scores were 6.6 and 6.4 in the conversion group and THA group, respectively. There have been no cases of aseptic loosening of the femoral or acetabular components in either group, and there have been no dislocations after MMRA conversion.

Conclusion: Conversion of failed MMRA to a THA appears to be as safe and effective as a primary THA.

We report 5 cases of linked shoulder and elbow replacement (LSER) following failure of single-joint arthroplasty. Whilst total humeral replacement has been reported for treatment following resection for tumour we know of no reports of linked shoulder and elbow prostheses for arthropathy alone. Between May and December 2005, 2 patients with total elbow arthroplasty and 3 patients with total shoulder arthroplasty were revised to LSER for loosening of the long humeral stems or periprosthetic fracture. Custom-made prostheses were produced using computer-aided design and manufacture technology. There were no early complications including infection. All 5 patients reported early improvement of symptoms, with the ability to bear weight axially through the limb, restored. This technique avoids the problem of a stress riser between the stems of separate shoulder and elbow replacements and solves the problem of salvage of long-stemmed implants where no further humeral fixation is possible.

We reviewed the clinical and radiological results of 131 patients who underwent acetabular revision for aseptic loosening with impacted bone allograft and a cemented acetabular component. The mean follow-up was 51.7 months (24 to 156).

The mean post-operative Merle D’Aubigné and Postel scores were 5.7 points (4 to 6) for pain, 5.2 (3 to 6) for gait and 4.5 (2 to 6) for mobility. Radiological evaluation revealed migration greater than 5 mm in four acetabular components. Radiological failure matched clinical failure. Asymptomatic radiolucent lines were observed in 31 of 426 areas assessed (7%). Further revision was required in six patients (4.5%), this was due to infection in three and mechanical failure in three. The survival rate for the reconstruction was 95.8% (95% confidence interval 92.3 to 99.1) overall, and 98%, excluding revision due to sepsis.

Our study, from an independent centre, has reproduced the results of the originators of the method.

Infection after total joint arthroplasty can present a diagnostic challenge. No preoperative tests are consistently 100% sensitive and specific, so the diagnosis of infection depends on the surgeon’s judgment with respect to the clinical presentation and examination and interpretation of the results of investigations. The consequences of misdiagnosis are severe. Reimplantation of a prosthesis into an infected host bed is likely to result in persistent infection.

Preoperative investigations include haematological screening tests (white blood cell count, ESR, and C-reactive protein), joint aspiration and arthrography, radiography, and radionuclide imaging studies. Intraoperative investigations include analysis of synovial fluid, gram-staining of tissue that appears inflamed, histological evaluation of frozen sections of inflamed tissue, and culture of periprosthetic tissue. The exclusion of infection as a cause of failure is imperative to determine the management of patients who need revision total joint replacement. The key to making the correct diagnosis is using not a single investigation but rather a correct combination of investigations.

From 2001 to 2004 we studied 46 patients referred from various centres with prosthesis loosening. The patients had technetium and gallium scintigraphy. In 32 patients, scintigraphic studies suggested septic loosening. Of these, 21 patients also had aspirations, three intraoperative cultures and 11 both aspirations and intraoperative cultures. The remaining 11 patients had aseptic loosening and were used as a control group. In only 10 patients was sepsis proved by aspiration or culture.

Our results, which show that scintigraphy has a dismal positive predictive value as a screening test and a good negative predictive value, concur with the current literature.

Introduction. Pathophysiology of glenohumeral arthritis differs depending upon type of arthritis. Osteoarthritis. Post-traumatic arthritis. Inflammatory arthritis (i.e. RA). Arthritis of instability. Crystalline arthritis (Milwaukee shoulder, cuff tear arthropathy). Avascular necrosis. Natural history as well as response to treatment are both pathology dependent. Soft-tissue involvement. Rotator cuff tear. Soft tissue contracture. Secondary osseous deformity. Regional osteopenia. Glenoid wear (concentric versus eccentric). Humeral collapse. Surgical options. Joint-sparing techniques. Arthroscopic capsular release/ joint debridement/synovectomy. Open debridement, subscapularis lengthening. Open capsular interposition. Osteotomy. Glenoid. Humeral. Cartilage transplantation. Arthrodesis. Resection arthroplasty. Joint replacement. Unconstrained. Hemiarthroplasty. Total shoulder replacement. Constrained. Joint-sparing Techniques. These techniques are only useful in patients with early changes or who are too young and active for joint replacement. Arthroscopic debridement or capsular release. Young patients. Normal joint alignment. Severe asymmetric capsular contracture (i.e. arthritis of instability). Open debridement. Large humeral osteophytes. Subscapularis lengthening. Open capsular interposition. Lateral edge of anterior capsule sutured to posterior labrum. Less severe degrees of contracture, subscapularis must be repaired anatomically. Osteotomy. Only useful in situations where there is abnormal humeral or glenoid alignment. Glenoid – posterior opening wedge for osteoarthritis in combination with posterior glenoid hypoplasia or increased retroversion. Humeral – most useful for post-fracture deformity (i.e. varus of the surgical neck). Cartilage Transplantation. Very early experience and really only attempted in any numbers in the knee. Chondrocyte transplantation very expensive and tedious. Currently, the most popular techniques involve transplanting plugs or cores of articular cartilage, subchondral bone, and cancellous bone. Autograft- harvest from non-weight-bearing or less weight-bearing area the same or different bone. Lateral femoral condyle. Posterolateral humeral head. Allograft. Early attempts limited by chondrocyte viability after harvest. Improved processing techniques have recently improved chondrocyte survival to 60–70%. Offers the desirable option of being able to preoperatively match radii of curvature of implant to donor site. Arthrodesis. Fortunately, rarely indicated. Patients miss the ability to rotate the humerus. Indications. Brachial plexus injury. Combined deltoid and rotator cuff deficiency. Young heavy labourer. Sepsis. Severe bone loss. Requires functional trapezius and serratus anterior. Resectional Arthroplasty (Jones Procedure). Even more rarely indicated than arthrodesis. Function is better if rotator cuff is attached to proximal humerus. Indications. Sepsis. Failed arthroplasty. Combined deltoid and rotator cuff deficiency. Conclusions. Hemiarthroplasty or total shoulder replacement with unconstrained implants is the surgical treatment of choice in the vast majority of patients with glenohumeral arthritis. Joint-sparing procedures are indicated in young patients with early, less extensive changes. Arthrodesis and resection arthroplasty are rarely indicated, except under unusual circumstances of soft-tissue deficiency, nerve injury, or sepsis. Cartilage transplantation shows promise in very select patients