Aims

Histology is an established tool in diagnosing periprosthetic joint infections (PJIs). Different thresholds, using various infection definitions and histopathological criteria, have been described. This study determined the performance of different thresholds of polymorphonuclear neutrophils (≥ 5 PMN/HPF, ≥ 10 PMN/HPF, ≥ 23 PMN/10 HPF) , when using the European Bone and Joint Infection Society (EBJIS), Infectious Diseases Society of America (IDSA), and the International Consensus Meeting (ICM) 2018 criteria for PJI.

Aims

This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect.

The June 2015 Trauma Roundup³⁶⁰ looks at: HIV-related implant surgery in trauma; Major transfusion under the spotlight; Surgery and mortality in elderly acetabular fractures; Traction pin safety; Obesity and trauma; Salvage of acetabular fixation in the longer term

Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of single-stage knee arthrodesis using an intramedullary cemented coupled nail without bone-on-bone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA.

Cite this article: Bone Joint J 2015;97-B:649–53.

Based on the first implementation of mixing antibiotics into bone cement in the 1970s, the Endo-Klinik has used one stage exchange for prosthetic joint infection (PJI) in over 85% of cases. Looking carefully at current literature and guidelines for PJI treatment, there is no clear evidence that a two stage procedure has a higher success rate than a one-stage approach. A cemented one-stage exchange potentially offers certain advantages, mainly based on the need for only one operative procedure, reduced antibiotics and hospitalisation time. In order to fulfill a one-stage approach, there are obligatory pre-, peri- and post-operative details that need to be meticulously respected, and are described in detail. Essential pre-operative diagnostic testing is based on the joint aspiration with an exact identification of any bacteria. The presence of a positive bacterial culture and respective antibiogram are essential, to specify the antibiotics to be loaded to the bone cement, which allows a high local antibiotic elution directly at the surgical side. A specific antibiotic treatment plan is generated by a microbiologist. The surgical success relies on the complete removal of all pre-existing hardware, including cement and restrictors and an aggressive and complete debridement of any infected soft tissues and bone material. Post-operative systemic antibiotic administration is usually completed after only ten to 14 days.

Cite this article: Bone Joint J 2013;95-B, Supple A:77–83.

Introduction: Hot swollen knee joints are a common presentation in clinical practice. It has wide differential diagnoses, the most serious being septic arthritis. Delayed or inadequate treatment leads to joint damage. Arthroscopic lavage should be planned appropriately after proper clinical assessment and investigation. Other differential diagnoses like crystal arthritis, reactive arthritis, monoarticular inflammatory arthritis should be considered.

Patients and Methods: This retrospective audit involved 44 patients who had arthroscopic knee lavage for suspected septic arthritis from January 2005 to May 2007. Analysis included the aspects of adequate backup supportive evidence for the procedure, the time from diagnosis to operation and postoperative antibiotic regime.

Results: There were 29 males and 15 females with age group ranging from 11 to 91 yrs. Fever was present in 15 patients(34%), preoperative joint aspiration done in 22(50%), peri-operatively pus found in 11(25%). 13 patients(29.5%) had procedure done within 6hrs, causal organism identified in 25%. Follow-up ranged upto 12 months without persistence or reactivation.

Discussion: Arthroscopic lavage is a useful adjunct in treatment of septic arthritis of knees but proper patient selection with systematic approach considering other possible differential diagnoses is important for avoiding unnecessary operations.

Saggital plane deformities are difficult to treat and pose major challenge to orthopaedic surgeons and we are presenting short series of patients who have undergone the deformity correction with ring fixator. Sixteen deformities in 15 patients were corrected during 1996 to 2004. The aetiology was congenital pterigium five cases, post traumatic seven cases, one each of polio, septic knee and post osteomyelitic sequelae. Nine patients had fixed flexion deformity, four had procurvatum and one had recurvatum and one patient had combined deformity. All cases were analysed with adequate x-rays two level fixation above and below the apex of the deformity was done with the hinges placed at the apex of the deformity. The motor was provided perpendicular to the axis of the hinge. Bony correction was performed in eight cases and rest were corrected by soft tissue distraction. After achieving correction fixator was retained for a month or two to prevent recurrence. Out of the eight cases of fixed flexion deformity (FFD) in nine knees, full correction was achieved in seven knees. One adult with septic knee was planned for correction of deformity and fusion which was completed in 4 months time. Out of five congenital pterigium three had full correction. One case had complete recurrence which was recorrected completely in the second attempt and the 5th case had residual 20 degree deformity. Knee deformity in PPRP patient underwent SC osteotomy with good correction of the deformity which compensated the quadriceps gait. Post traumatic FFDs were corrected fully. The bony deformities of tibia namely the procurvatum and recutvatum deformities were corrected fully. Average fixator time is 7 months

Introduction and Objectives: There are knee prostheses that are specifically designed for the treatment of extreme cases of surgical revision of cases with large bone losses. These are hinged systems that provide greater stability and have a wide range of components to reconstruct bone defects Experience with this type of prosthesis is usually limited, due to the fact that it is used in complex and sporadic cases. Our aim is to review the results obtained with the implant of this prosthesis in our unit. Materials and Methods: From June 2000 until March 2008 we implanted 10 salvage knee prostheses (5 TKR OSS, 5 TKR FINN). These procedures were carried out in 6 women and 4 men of 33 to 77 years of age. Indications for these procedures were many, with predominance of revision surgery of septic knee, bone tumors and failure of an infected osteosynthesis. Results: We achieved pain relief in 7 patients: Mean morbidity > 45° in 7 cases. And 90% of the patients were satisfied. Discussion and Conclusions: Large bone defects are difficult to reconstruct, especially when a joint is affected. Revision surgery is difficult and has poor results. Knee salvage prostheses are capable of providing a stable non-painful knee in severely incapacitated patients. We had few complications and we hope to have more cases and be able to carry out a longer follow-up of the ones we had. We are optimistic and we have named this prosthesis ‘the third knee prosthesis’

Infection of total knee replacement (TKR) is considered a devastating complication, which necessitates complete removal and thorough debridement of the site. Usually long term antibiotic treatment and a multitude of surgical interventions within a period of several months are required until a definitive supply can be achieved. Osseous defects are common in such conditions and need to be addressed during re-implantation. Managing removal, debridement, reconstruction and re-implantation within a single operation is the ideal solution, both for the patient and the treating team, but rarely executed due to the fear of re-infection. Allograft bone may be impregnated with high loads of antibiotics using a special incubation technique. The resulting antibiotic bone compound (ABC) provides high and long lasting antibiotic levels at the site of infection and is likely to restore bone stock. We have investigated the results of one-stage exchange of infected TKR using ABC together with uncemented implants.

Between 1998 and 2004 nineteen exchange procedures of infected TKRs were performed in a single stage, all of them without the use of bone cement. After removal of the implants and radical debridement bone voids were filled with ABC using a modified impaction technique. Consequently, new uncemented implants were inserted. We mainly used the revision type of the LCS knee (DePuy, J& J) as long as ligamentary stability was considered sufficient. Otherwise, we used a custom-made uncemented version of the LINK Rotational Endo Model. Joints were drained and closed immediately; rehabilitation did not differ from uninfected revision.

One knee required re-revision because of persisting infection. The remaining 18 patients stayed infect-free for a period between 2 and 8 years after surgery. In two knees loosening was found after one year, once of the tibial and once of the femoral component. Both were found infect-free at the time of re-revision. All could be successfully revised using the same technique again. No adverse side effects could be found. Incorporation appeared as after grafting with unimpregnated bone grafts.

Using antibiotic-impregnated allografts eradication of pathogens, grafting of defects and re-insertion of an uncemented prosthesis may be accomplished in a one-stage procedure. Since the graft gradually is replaced by healthy own bone, improved long-term results may be expected as well as improved conditions in the case of another revision.

Introduction: Knee arthrodesis is a well-recognized salvage procedure in patients with septic destruction of the knee joint. If fusion can be achieved, it offers the opportunity for a stable lower limb and eradication of infection, but at the expense of knee motion. However, knee arthrodesis in this setting may be difficult to achieve because of poor bone stock, persistent infection and soft tissue compromise. In this study we present clinical and radiological results after knee fusion as well as an algorithm according to different surgical techniques (hybrid external fixator (HEF), antegrad compression nail (ACN) and modular cement less titanium rod (MCR)) and types of soft tissue damages and bone loss caused by infection

Patients and Methods: Between 10/2000 and 10/2002 in 37 patients knee arthrodesis was indicated after septic joint destruction. In 23 Pat. (67.0 y, 19.4–88,8 y) septic failure of total knee arthroplasty (TKA)caused severe bone loss and soft tissue damage. Because solid bony fusion was not to be expected weight bearing capability was restored by the use of MCR in a second stage procedure, using a PMMA Gentamycin spacer for eradication. In 14 Pat. (54.3 y, 23.l–87.7 y) remaining bone stock indicated direct fusion. In 10 of these cases HEF was used (6x primary joint infection, 3x septic failure of TKA, lx infected osteosynthesis). 2 pat. denied written consent for HEF, another 2 pat. had infected ipsilaterale midshaft femor-and/or tibia non unions. Because of these we used the ACN.

Results: In 5 pat. (21.7%) treated with MCR 1,4 revision procedures were indicated to eradicate infection before the implantation of MCR. Recurrence of infection after implantation occurred in 13% (n=3): 2 pat. were treated non surgically, lx amputation had to be done. No radiological signs for implant loosening were seen. HEF was removed after 15 weeks (12–18w) on average. 5 revision procedures were necessary in HEF cases (lx Pin-, lx ring exchange, lx sequestrectomy after pintractinfection,)- hi 2 cases the procedure was changed to MCR because of a non-union. Using the ACN we saw a 100% fusion rate, in one case the sinus tract persisted. The check up examinations were done 8,7 month (2,4–22,4mo) after arthrodesis procedure. 82,6% of pat. after MCR, 100% after HEF- and ACN-had full weight bearing capability. Eradication of infection was achieved in 86,9% (n=20) after MCR, in 70% (n=7) after HEF and in 75% (n=3) after ACN. In all 3 groups soft tissue reconstruction by flap surgery was indicated in 20%.

Conclusion: HEF is indicated when bone loss allows bony fusion. Failure occurred when bone defects were underestimated ort he fixator was removed before the 14th week. MCR can be used when eradication of infection is success and because of bone defects direct fusion is not possible. When eradication is not possible and bone stock makes the fusion reliable the ACN can be used under ongoing infection. ACN is also used when HEF is not recommended by the patient or because of mechanical reasons (floating knee).

Introduction and Objectives: Arthrodesis of the knee is the method that most readily controls septic processes and results in a non-painful, stable knee joint. However, the disadvantages of this technique are shortening of the limb and a loss of joint function.

Materials and Methods: We present here our unit’s experience in the use of the Orthofíx ® transport system on the anterior surface to stabilise this type of arthrodesis. We used radiological techniques to evaluate the alignment and coaptation of the surfaces to be arthodesed. We also assessed functional capacity, postoperative patient satisfaction, rate of repeat arthrodesis, consolidation time, and complications associated with this method.

Results: According to our results, femorotibial arthrodesis with the bone transport system provides all the advantages of monolateral external fixation while allowing compression of the point of arthrodesis, achieving perfect coaptation, and providing extraordinary rigidity to the mounting.

Discussion and Conclusions: As with all other procedures, femorotibial arthrodesis has its complications. The complication directly related to knee arthrodesis is femorotibial non-union, which is correlated with a loss of bone stock, incomplete coaptation, poor alignment of the limb, persistent infection, and inadequate immobilisation. We believe this procedure produces a functional limb with significant relief of pain in most patients.