Aims. Bacterial infection activates neutrophils to release neutrophil extracellular traps (NETs) in bacterial biofilms of periprosthetic joint infections (PJIs). The aim of this study was to evaluate the increase in NET activation and release (NETosis) and haemostasis markers in the plasma of patients with PJI, to evaluate whether such plasma induces the activation of neutrophils, to ascertain whether increased NETosis is also mediated by reduced DNaseI activity, to explore novel therapeutic interventions for NETosis in PJI in vitro, and to evaluate the potential diagnostic use of these markers. Methods. We prospectively recruited 107 patients in the preoperative period of prosthetic surgery, 71 with a suspicion of PJI and 36 who underwent arthroplasty for non-septic indications as controls, and obtained citrated plasma. PJI was confirmed in 50 patients. We measured NET markers, inflammation markers, DNaseI activity, haemostatic markers, and the thrombin generation test (TGT). We analyzed the ability of plasma from confirmed PJI and controls to induce NETosis and to degrade in vitro-generated NETs, and explored the therapeutic restoration of the impairment to degrade NETs of PJI plasma with recombinant human DNaseI. Finally, we assessed the contribution of these markers to the diagnosis of PJI. Results. Patients with confirmed PJI had significantly increased levels of NET markers (cfDNA (p < 0.001), calprotectin (p < 0.001), and neutrophil elastase (p = 0.022)) and inflammation markers (IL-6; p < 0.001) in plasma. Moreover, the plasma of patients with PJI induced significantly more neutrophil activation than the plasma of the controls (p < 0.001) independently of tumour necrosis factor alpha. Patients with PJI also had a reduced DNaseI activity in plasma (p < 0.001), leading to a significantly impaired degradation of NETs (p < 0.001). This could be therapeutically restored with recombinant human DNaseI to the level in the controls. We developed a model to improve the diagnosis of PJI with cfDNA, calprotectin, and the start tail of TGT as predictors, though cfDNA alone achieved a good prediction and is simpler to measure. Conclusion. We confirmed that patients with PJI have an increased level of NETosis in plasma. Their plasma both induced NET release and had an impaired ability to degrade NETs mediated by a reduced DNaseI activity. This can be therapeutically restored in vitro with the approved Dornase alfa, Pulmozyme, which may allow novel methods of treatment. A combination of NETs and haemostatic biomarkers could improve the diagnosis of PJI, especially those patients in whom this diagnosis is uncertain. Cite this article: Bone Joint J 2024;106-B(9):1021–1030

Purpose of the study: The aim of this work was to determine whether erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and alpha-1-antitrypsin (A1AT) levels are correlated significantly with early postoperative infectious complications after hip prosthetic surgery. Materials and methods: This prospective study was conducted on 100 total hip replacements performed between 1994 and 1995. ESR, CRP and A1AT were obtained before surgery then at 1, 2 and 6 weeks after surgery. Results: Seven bacteriologically proven cases of infection were reported. Infection was considered to be superficial if it did not extend deeper than the muscles fascia. There was a strong statistical correlation between A1AT level and infection for all postoperative times (p < 0.0001). A1AT was highly sensitive (87.5 p. 100) and specific (85.8 p. 100) for infection compared with ESR (sensibility 70 p. 100 and specificity 65.9 p. 100) and CRP (sensitivity 63.6 p. 100 and specificity 80.1 p. 100). Discussion and conclusion: In our hands, A1AT can be a most useful diagnostic tool for infection after prosthesis hip surgery. Although not totally specific, it is highly sensitive for infection compared with other tools such as ESR and CRP more frequently used. These findings suggest an avenue of research on the role of A1AT in infectious complications after prosthetic joint surgery

Purpose: The indication for humeral or total shoulder prosthesis in patients with avascular osteonecrosis of the shoulder depends on the radiographic stage of the necrosis. The purpose of this study was to analyse the prognostic radiographic features enabling proper identification of the indications for humeral or total prostheses. Material and methods: This retrospective multicentric study included 53 shoulders operated on for prosthetic repair of avascular osteonecrosis. There were 20 men and 29 women, mean age 57 years. A humeral prosthesis was used in 34 cases and a total prosthesis in 19. Clinical assessment was based on the Constant score and the radiographic analysis used the Arlet and Ficat classification. Staging was II (n=4), III (n=16), IV (n=21) and V (n=12). Independently of the radiographic stage of necrosis, three characteristic groups were defined. Group 1 (19 shoulders) included necrosis without bony collapse of the humeral head. Group 2 (20 shoulders) included necrosis with bony collapse of the humeral head with preservation of the anatomic relations with the glenoid cavity. Group 3 (14 shoulders) included necrosis with bony collapse and impaction of the humeral head in the glenoid with medialisation of the humerus. Results: Preoperatively, presence of bony collapse was associated with decreased pain and motion score. Major joint stiffness was noted in group 3 (8). The humeral prosthesis gave similar results for groups 1 and 2 (Constant score 73 and 75.3). Less satisfactory results was the rule in group 3 (Constant score 51.6). There was a postoperative erosion of the glenoid cavity in 83% of the shoulders in group 3 versus 12.5% in group 1 and 17% in group 2. The total prosthesis optimised results despite persistence of a difference between groups 2 and 3 (Constant score 83 and 64 respectively). Discussion: Destabilisation of the glenohumeral joint by impaction of the humeral head against the glenoid cavity has an effect on the clinical result of the prosthetic surgery. Preservation of the anatomic relations of the articulation (groups 1 and 2) appears to be necessary for good results. Impaction medialisation of the humerus has a negative effect on the clinical result of humeral prostheses with a risk of glenoid erosion. Conclusion: Independently of radiographic stage of necrosis, the presence of humeral impaction with medi-alisation should be considered individually as it has a negative effect on the clinical outcome of these prostheses, particularly humeral prostheses

The aim is: to point out, in respect of Italian case law trends, the concept and the boundaries of surgeon malpractice liability in evaluating and implanting new prosthesic materials.

The surgeon is liable for damages caused by fraudulent intention or fault during his clinical and operating activity. In a civil perspective, it could be the result of either a breach of a contract or a tort, depending on the existing relationship between the surgeon and the patient; but in both case there might be a serious inexperience or a light imprudence or negligence to admit a fair compensation for damages. While in a criminal perspective, the personal injuries might be the result of a serious fault also in the area of imprudence and negligence to admit the application of criminal sanctions. Of course, personal liability of surgeon stands by vicarious liability of health unit.

Civil sanctions are more effective than criminal sanctions, not only because they have a wider area of application, but also because they are more incisive in quantitative terms, considering the new guidelines on pecuniary and biological damages that make out, at the same time, a compensatory and punitive function.

The surgeon, to be sure not to be affected by civil and criminal actions, might inform the patient about the operating features and the consequences of non operating, follow standardized protocols, use products and materials tested and certified by the most influential scientific literature, be care of post-operating effects and adopt all remedies and treatments that can eliminate or reduce post-operating risks, use the best and up-to-date techniques available. In any case he is not liable for unforeseeable events, even if they are in a causative relationship with surgical activity.

Purpose

To assess the reliability of a biomimetic osteochondral scaffold Maioregen (Finceramica Faenza SpA, Faenza, Italt) as a salvage and joint-preserving procedure in the treatment of late stages of osteonecrosis of the knee.

Total temporomandibular joint (TMJ) replacements reduce pain and improve quality of life in patients suffering from end-stage TMJ disorders, such as osteoarthritis and trauma. Jaw kinematics measurements following TMJ arthroplasty provide a basis for evaluating implant performance and jaw function. The aim of this study is to provide the first measurements of three-dimensional kinematics of the jaw in patients following unilateral and bilateral prosthetic TMJ surgeries. Jaw motion tracking experiments were performed on 7 healthy control participants, 3 unilateral and 1 bilateral TMJ replacement patients. Custom-made mouthpieces were manufactured for each participant's mandibular and maxillary teeth, with each supporting three retroreflective markers anterior to the participant's lip line. Participants performed 15 trials each of maximum jaw opening, lateral and protrusive movements. Marker trajectories were simultaneously measured using an optoelectronic tracking system. Laser scans taken of each dental plate, together with CT scans of each patient, were used to register the plate position to each participant's jaw geometry, allowing 3D condylar motion to be quantified from the marker trajectories. The maximum mouth opening capacity of joint replacement patients was comparable to healthy controls with average incisal inferior translations of 37.5mm, 38.4mm and 33.6mm for the controls, unilateral and bilateral joint replacement patients respectively. During mouth opening the maximum anterior translation of prosthetic condyles was 2.4mm, compared to 10.6mm for controls. Prosthetic condyles had limited anterior motion compared to natural condyles, in unilateral patients this resulted in asymmetric opening and protrusive movements and the capacity to laterally move their jaw towards their pathological side only. For the bilateral patient, protrusive and lateral jaw movement capacity was minimal. Total TMJ replacement surgery facilitates normal mouth opening capacity and lateral and inferior condylar movements but limits anterior condylar motion. This study provides future direction for TMJ implant design

Introduction: The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty, in addition previous femural osteotomy can deformate proximal femur.

Despite the fact that uncemented cup and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe IV and sometimes Crowe III additional surgical procedure are required.

Purpose of the study is to analize surgical procedure and then reconstruction options on severe hip dysplasia.

Materials and methods: From 1984 till today 2308 cases of arthroplasty were performed in dysplastic hip, 565 cases have a previous femoral osteotomy; out of these 2308 cases 128 cases need treatment for corrections of femural side deformity.

64 cases were subjected to a greater trochanteric osteotomy. In 12 cases proximal femural shortening was associated. In 9 cases rotational abnormality and shortening were controlled with a distal femur osteotomy.

55 cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only uncemented stems were used and in the majority of cases a specific device for displastic hip (Wagner Conus produced by Zimmer).

Discussion: Long-term results in these patients are steadily inferior to that in the general population (70% survival at 15 yrs). On femural side early failures are the reflection of learning curve and are due to insufficient fixation of the osteotomy.

Despite this, the more promising outcomes are concerning shortening subtrochanteric osteotomy with uncemented stem but only early and mid-term data are available.

Introduction: Angular and torsional deviations of femur are usually combined with Congenital Dislocation of the Hip (CDH) and increase the complications of hip arthroplasty. The aim of this study is to evaluate surgical and reconstructive options for the treatment of CDH.

Material and Methods: In this retrospective study, we evaluated the results and complications of 55 primary cementless total hip arthroplasties, all of whom had Crowe type-IV developmental dysplasia of the hip. The arthroplasty was performed in combination with a subtrochanteric shortening osteotomy and with placement of the acetabular component at the level of the anatomic hip center. The patients were evaluated at a mean of 8,1 years postoperatively.

Results: From 1984, more than 2000 cases of arthroplasty have been performed in dysplastic hip, 565 cases had a previous femoral osteotomy; 128 cases needed correction of femoral side deformity; 64 had a greater trochanteric osteotomy. In 9 cases rotational abnormality and shortening were controlled with plate and distal femur osteotomy. 55 cases were treated by a shortening subtrochanteric osteotomy. Only non-cemented stems were used. 4 failures occurred for the incorrect fixation of the metaphysis. The fixation can be obtained only by prosthetic press-fit, but it is preferable to use metal wires. There was no sciatic injury; indeed shortening osteotomy provides an easy control of deformity and lengthening, with a maximum of 4 cm. One case was reviewed for heterotopic calcification (grade 4). One infection of the soft tissue was medically cured. There were two revisions for polyethylene failure at 8 and 12 years postoperative.

Discussion: The anatomic abnormalities associated with CDH and previous femoral osteotomy increase the complexity of hip arthroplasty. We had best results with the femoral shortening subtrochanteric osteotomy where a rapid consolidation was obtained. Moreover, the functional result was better for the management of the insertion of the muscle tendons in particular the mediogluteus and also for the relatively correct positioning in favour of the reciprocal relationship of the pelvic-trochanter. The detachment of the greater trochanter associated with a metaphyseal proximal shortening, remains an effective technique for the treatment of malformations that are difficult to treat, but there is a high risk of pseudarthrosis of greater trochanter.

Conclusion: Femoral shortening subtrochanteric osteotomy preserves the proximal femoral anatomy, avoids the problems associated with reattachment of the greater trochanter, and facilitating a cementless femoral reconstruction in relatively young patients.

Introduction: Many publications have already shown the great interest of dual-mobility concept which significantly reduces the rate of prosthetic dislocation and thus find its place for patients at high risk of post operative instability. The aim of our study is to evaluate the prevalence of prosthetic instability in revision total hip arthroplasty using a dualmobility cup.

Materials and Methods: Our multicentric series consists of 163 revision total hip arthroplasties performed between may 1999 and may 2004. The mean age at revision was 70 years and the mean follow-up period was 56 months.

The primary etiology necessitating revision is aseptic loosening.

According to the SOFCOT classification, the acetabular deficiency was grade IV 9 times, grade III 47 times, grade I or II 107 times.

All the implanted acetabular components are SERF dual-mobility implants. This system consists of a metal back which can be HA-coated and Press Fit or cemented in a Kerboull cross or in a Novae Arm. The mobile-bearing insert which allows a dual articulation between the head and the metal back is of polyethylene.

We implanted 119 HA-coated press-fit cups and cemented 44 dual-mobility cups in a support ring or in a Kerboull cross.

Results: The mean Merle d’Aubigné and Postel score is 14,1 at the last follow-up and 4,2 in the preoperative period.

We reported 8 complications: 6 early dislocations and 2 acetabular revisions for secondary mobilisation of the cup.

Discussion: According to Huten’s 1996 SOFCOT teaching conference, this rate ranges between 2 and 5% and we have already published a series of 106 dual-mobility with no dislocation at a 10 year follow-up period.

With 4% dislocations at a mean follow-up of 56 months, the dual-mobility cup seems to provide high stability in revision hip surgery when other factors such as muscular deficiency, extended synovectomies, difficult implant placement, encourage an uncertain postoperative prosthetic stability.

These results have to be compared to those of other systems such as constrained acetabular cups or tripolar cups.

Conclusion: This is why dual-mobility remains an efficient and reliable choice to avoid prosthetic dislocation in revision surgery. Moreover, we encourage the use of dual-mobility cup in any high risk situation in terms of post-operative instability such as for old or neurological patients.

From 1998 to July 2003 admissions for elective arthroplasty surgery in Derriford Hospital were nursed alongside other orthopaedic and general medical patients. Since August 2003 a policy of pre-operative MRSA screening and a unit reserved exclusively for MRSA-free joint replacement patients have been used. No transfers from other wards were allowed. Patients positive on screening underwent eradication and were admitted to a different ward where they received teicoplanin on induction (in addition to standard policy cephradine). All post-operative wound infections following THR & TKR were monitored (NINSS surveillance system). Infections within 3 months were recorded. A control of non-screened hip hemi-arthroplasty patients was used to ensure a departmental wide reduction in MRSA was not occurring.

1.9% MRSA carriage rate was detected over the study. Before screening, 0.59% of 3386 cases were acutely infected with MRSA. After institution of screening and a dedicated MRSA free unit, 0.10% of 1034 were acutely infected. This was a 6-fold decrease (p<0.05). The infection noted was in a patient treated outside the ringfenced unit on High Dependency. In fact the infection rate on the ringfenced unit was zero. MRSA infection in the control was statistically unchanged during this period.

Since Aug‘03 pre-operative MRSA screening & a ward reserved exclusively for MRSA free joint replacement patients has been used. All postoperative wound infections within 3 months following THR & TKR were monitored.

Before screening, 0.59% of 3386 were acutely infected with MRSA. After institution of study policy, 0.10% of 1034, were infected with MRSA.. This was a 6 fold decrease (p< 0.05). The rate of MRSA infection in a control of hemiarthroplasties was unchanged during this period.

A policy of MRSA screening & an MRSA free joint replacement ward reduces the incidence of acute MRSA infections.

The use of implant biomaterials for prosthetic reconstructive surgery and osteosynthesis is consolidated in the orthopaedic field, improving the quality of life of patients and allowing for healthy and better ageing. However, there is the lack of advanced innovative methods to investigate the potentialities of smart biomaterials, particularly for the study of local effects of implant and osteointegration. Despite the complex process of osseointegration is difficult to recreate in vitro, the growing challenges in developing alternative models require to set-up and validate new approaches. Aim of the present study is to evaluate an advanced in vitro tissue culture model of osteointegration of titanium implants in human trabecular bone. Cubic samples (1.5×1.5 cm) of trabecular bone were harvested as waste material from hip arthroplasty surgery (CE AVEC 829/2019/Sper/IOR); cylindrical defects (2 mm Ø, 6 mm length) were created, and tissue specimens assigned to the following groups: 1) empty defects- CTR-; 2) defects implanted with a cytotoxic copper pin (Merck cod. 326429)- CTR+; 3) defects implanted with standard titanium pins of 6 µm-rough (ZARE S.r.l) -Ti6. Tissue specimens were cultured in mini rotating bioreactors in standard conditions, weekly assessing viability. At the 8-week-timepoint, immunoenzymatic, microtomographic, histological and histomorphometric analyses were performed. The model was able to simulate the effects of implantation of the materials, showing a drop in viability in CTR+, differently from Ti6 which appears to have a trophic effect on the bone. MicroCT and histological analysis supported the results, with lower BV/TV and Tb.Th values observed in CTR- compared to CTR+ and Ti6 and signs of matrix and bone deposition at the implant site. The collected data suggest the reliability of the tested model which can recreate the osseointegration process in vitro and can therefore be used for preliminary evaluations to reduce and refine in vivo preclinical models. Acknowledgment: This work was supported by Emilia-Romagna Region for the project “Sviluppo di modelli biologici in vitro ed in silico per la valutazione e predizione dell'osteointegrazione di dispositivi medici da impianto nel tessuto osseo”

The surgical treatment of a secondary gonarthrosis caused by haemophilic arthropathy needs high quality in soft tissue balancing and accurate alignment in total knee arthroplasty (TKA), which are essential for good long-term results. Due to the early-onset severe arthropathy, haemophiliacs undergo prosthetic surgery at a younger age than general population; therefore to ensure a longer duration of implantation is a major objective to be reached in this setting. As several prospective randomised studies could show, Computer navigation in prosthetic surgery improve precision concerning geometry of axes, resection planes and implant alignment, by the determination of joint centres (actual axis), amount of bone resection, size of prostheses and check of ligament balance. At our department, since January 2006, we implanted four TKA in four patients (age range 45–52 years) affected by severe Haemophilia B; the same surgeon used a single system (Orthopilot system) in all cases. The quality of implantation was studied on postoperative standardized long leg coronal and lateral x-rays. Our results showed that CAS had greater consistency and accuracy in implant placement. Complications influencing the clinical outcome did not occur. In our experience, drawbacks of the navigation systems are the additional costs and the additional operation time between 15 and 25 min. However, one of the most important advantages of using of this technique in patient affected by coagulation disease, according to the international literature, is the reduction of blood loss after operation. A long-term follow-up of these and of larger samples of patients is needed for testing cost/risk-benefit ratio of Orthopilot in prosthetic surgery of haemophiliacs. Therefore navigated total knee arthroplasty in haemophilic arthropathy is not yet a standard procedure, but this technique could become an important surgical choice in management of severe secondary osteoarthritis in the future

Post-surgical infections are still one of the most frequent adverse events in the prosthetic surgery. PMMA-based cements are widely employed in orthopaedic surgery as filler or prosthetic fixing device. The main problems associated with this material are poor bone integration and infection development. Aiming to avoid bacterial adhesion and to extend the longevity of implants, different solutions were proposed, both in terms of operative procedures and new materials development. Regarding the materials advancement, innovative PMMA-based composite bone cements, contemporaneously bioactive and antibacterial (without the use of antibiotics), were developed. The composites are based on a PMMA matrix containing a bioactive glass, doped with antibacterial ions (Ag+ or Cu++); so, the same filler shows at the same time the ability of promoting bone ingrowth and an antibacterial effect. Composite cements were characterized in terms of morphology and composition, curing parameters and mechanical properties; in vitro tests were performed to verify the material ability to release antibacterial ions and to promote the precipitation of hydroxyapatite. Moreover, cytotoxicity and antimicrobial properties were verified. The cements characteristics were tested using different commercial matrix and different viscosities; therefore, the proposed formulations represent an innovative solution for a new family of antibiotic-free, bioactive and antibacterial cements

Aims

We performed a systematic literature review to define features of patients, treatment, and biological behaviour of multicentric giant cell tumour (GCT) of bone.

Introduction and Objectives: In this study we assessed the usefulness of preoperative urine cultures as a tool to prevent infections due to Gram negative microorganisms in patients undergoing prosthetic surgery. Materials and Methods: In 2007 procedures were carried out to implant 259 knee prostheses and 101 hip prostheses, 47 of these were revision procedures. Pre-operative exams included urine culture to detect asymptomatic bacteriurias which could be treated before surgery with positive results. A urinary catheter was placed in all patients and removed after 24 hours. Results: Asymptomatic bacteriuria was found in 13% of patients. In 6 patients the urine culture was positive for more than one microorganism. The most frequently found pathogen was E. coli. All cases were treated with antibiotics and a new urinary culture was carried out before surgery. Our infection rate is 0.8% in primary hip replacements and 8.1% in revisions. And 1.9% in primary knee replacements and 6.7% in revisions. An infection caused by a Gram negative microorganism in a revision THR was caused by a subclavian catheter colonized by Pseudomona aeruginosa. Discussion and Conclusions: Our preoperative studies protocol includes urine culture. We have not seen any TKR or THR infections caused by Gram negative microorganisms. Therefore, based on this, we suggest that preoperative urine culture is useful to identify asymptomatic bacteriuria and treat it, thereby avoiding infections caused by Gram negative microorganisms in patients undergoing prosthetic surgery

Aim. Prosthetic joint infections (PJI) due to Enterobacter cloacae are rare and often severe. The aim of this study is to describe cases with E. cloacae PJI. Method. We conducted a retrospective and a monocentric study in an orthopedic unit where complex bone and joint infections are managed. From 2012 to 2016, we included patients with PJI which perioperative samples were positive with E. cloacae. We collected background, clinical, biological and microbiological data of the current infection, surgical and medical treatment, and the outcome of these patients. Results. A total of twenty patients were included which 8 were male. Location was hip in 14 cases, knee in 5 cases and ankle in one case. The median time between arthroplasty and revision for infection was 3 years. Fourteen patients had at least two surgeries for previous PJI. The median time between the last surgery and the revision for E. cloacae infection was 31 days. Eleven patients were infected by extended-spectrum beta-lactamases (ESBL) strains. Most frequently, the antibiotics used were carbapenem in 9 cases, cefepim in 7 cases, a quinolone in 7 cases and fosfomycin in 4 cases. Infection was cured in 10 cases (50%) with a median time of follow-up of 24 months. Five patients had a recurrent infection, three due to Staphylococcus epidermidis, one to Staphylococcus epidermidis and Propionibacterium acnes and one to Escherichia coli. Four patients had a relapse of E. cloacae infection. One patient died from non-infectious cause (stroke). Conclusions. PJI infections due to E.cloacae usually occur early after the last prosthetic surgery, typically in patients with complex surgical history. A poor outcome, observed in nearly half of the patients could be explained in part by an association of factors: multiple risks factors, complex infectious history, a high rate of multiple resistance to antibiotics, unfavorable skin conditions

Aim. When a prosthetic joint infection (PJI) is suspected, guidelines recommend performing periprosthetic samples, at least one for histopathological examination and 3 to 6 for microbiological culture. The diagnosis of infection is based on the presence of neutrophil granulocytes whose number and morphology can be variable, resulting in definition of “acute” inflammation. The acute inflammation of periprosthetic tissue is supportive of infection. Since 2007, in our hospital, for all patients with suspected PJI who underwent surgery, from each sample taken by the surgeon, one part has been sent to the pathologist and the other one to the microbiologist. Our aim was to compare histopathological to microbiological results from samples taken intraoperatively at the same site. Method. We conducted a retrospective study including all surgeries for which at least one couple “histopathology-culture” was found. Exclusion criterion was a history of antimicrobial treatment 2 weeks prior the surgery. Results. From July 2007 to April 2015, 309 surgeries for suspected PJI were performed in 181 patients. Median age of the study population was 70 years, 60% of patients were male, 45% had a history of joint infection. The location of arthroplasty was knee in 50% of cases and hip in 46%, ankle and shoulder in 4%. Surgery was performed within one month after the last prosthetic surgery in 15% of cases. According to the criteria from the Musculoskeletal Infection Society, 60% of cases should have been considered as having an infection. The median number of samples per surgery was 4 (IQR 3–5) for histopathological examination and 5 (IQR 4–6) for culture. Finally, 1247 couples “histopathology-culture” were available. Among them, histopathological examination showed acute inflammation in 292 cases (23%) and subacute inflammation in 327 cases (26%). Microorganisms considered to be pathogenic were found in 582 samples (47%). The presence of neutrophil granulocytes was well correlated with the presence of those microorganisms (OR=4.1; IC 95% 3.1–5.5). As expected, the highest correlation between acute inflammation and positive culture was observed for early infection (< 1 month) (OR = 9; 3.6–23.4) and Staphylococcus aureus infection (OR = 4.8; 3.3–7.0). There was no correlation between acute or low-grade inflammation and anaerobic or Candida infection. Conclusions. Our results confirmed histopathological examination is better correlated with culture in acute infection and/or infection due to highly virulent bacteria but must be interpreted with caution in case of chronic infection or infections due to microorganisms with low virulence

PJI du to Enterobacter cloacae are rare and often severe. The aim of our study is to define the history of patients with such infections and their outcome. We conducted a retrospective monocentric study in an orthopedic unit where complex bone and joint infections are supported. From 2011 to 214 we selected patients with E. cloacae PJI based on data from the microbiology laboratory. In their files we collected information on their background, their medical and surgical history, antibiotics they received in the year before infection, the suspected portal of entry, the management and the outcome. Twelve patients were included, 7 male and 5 female. PJI was located to the hip in 8 cases, the knee in 3 cases and the ankle in one case. The average time between the placing of the first prosthesis and infection was 3 years. Eleven patients had one or more surgery for previous PJI. The average time elapsed since the last surgery was 30 days. Eleven patients had been treated with antibiotic combinations for at least 6 weeks, in the year before E cloacae infection. A portal of entry was identified only two times: urinary tract infection in one patient and catheter-related infection in one patient. Antibiotics the more often prescribed were carbapenems (n = 5) and cefepime (n = 4), each combined with quinolones (n =4) or fosfomycin (n = 3). Two patients required an additional debridement within an average of 18 days. Infectious outcome was favorable in 8 cases (67%) with a median duration of follow-up of 26 months. Two patients had a recurrent infection, one due to Streptococcus oralis and one to Candida albicans. One patient had a relapse of E cloacae infection. One patient died from unknown cause. PJI infections due to E.cloacae usually occur early after prosthetic surgery, typically in patients with complex surgical history. Despite a high rate of multi-resistance to antibiotics, outcome may be favorable in a large majority of patients

Haemophilia is a lifelong inherited bleeding disorder characterized by spontaneous bleeding resulting in painful joint deformities. Even if prosthetic surgery and the effectiveness and safety of clotting factor concentrate have improved the therapeutic options available, sometimes the orthopaedic surgeon has to treat substance losses. First, we have to distinguish: 1) sub-chondral cysts, 2) intra-osseous cysts, 3) pseudo-tumour (a chronic expanding blood cyst with the ability to displace and destroy adjacent tissues) Surgical treatment is in relation to its anatomical location and extension and is always associated with prolonged treatment with clotting factor concentrate. In our 20 years’ experience, we have used several therapeutic options. In some cases, we use filling with bone graft and fibrin seal and today platelet derived growth factor; in the others we have used amputation or custom made prosthesis

Introduction and purpose: To assess the long-term results of Coventry-type tibial osteotomies performed in our center. Materials and methods: This is a retrospective study. We carried out a review of 324 histories of Coventry-type osteotomies selected from a total of 76 with a mean follow-up of 12.9 years (minimum 5, maximum 25). We reviewed the patients’ preoperative assessment, postoperative assessment and last assessment or consultation before a total knee replacement. We also looked at the clinical evaluation of the patients’ pain, degree of arthritis on x-ray (Ahlbäck) and degree of postoperative correction obtained. Results: 76 cases. Mean age 57.9 years (range: 35–72). Radiological degree of arthritis: 36.8% slight; 57.9% moderate; 5.2% severe. We found that patients with slight arthritis at the end of follow-up (mean 12.5 years) had 71% of satisfactory results. Satisfactory results were seen in 50% of patients with moderate arthritis (mean follow-up 16 years). With reference to the degree of correction, patients with mild over-correction had better results (8–12° valgus), followed by those normally corrected (0–8° valgus). A total of 30 patients (41%) required TKR at the end of their evolution (mean period of 13 years to TKR). Conclusions: In spite of the advances of prosthetic surgery, the Coventry osteotomy continues to be appropriate in mild to moderate single-compartment arthritis. In the long term slight over- correction provides better outcomes

Purpose of the study: Prevention of operative site infections (OSI) in orthopaedic surgery requires strict observation of validated practices during hospitalisation and in the operative theatre, review of morbidity and mortality, and surveillance of OSI. Certain intrinsic patient-related risk factors of OSI cannot be controlled without direct implication of the patient and the referring physician. Search for Staphylococcus aureus (SA) colonisation and bacteriuria should be done in the ambulatory setting, before hospitalisation. The purpose of this work was to evaluate the feasibility of a search for SA in the nasal swabs and urine samples in patients scheduled for prosthesis surgery. Material and methods: This was a prospective study on 335 patients who had a total hip arthroplasty (THA) or a total knee arthroplasty (TKA) from January 1, 2007 to December 31, 2008. Bacteriological tests were performed before hospitalisation. Before hospitalisation, the patient and the primary care physician were give information on the proper procedure for chemical decontamination. The results of these laboratory tests were analysed and OSI were followed. Results: Three hundred thirty-five patients (195 THA and 143 TKA) were included; the sex-ratio was 0.95 M/F. Sixty-one patients (18%) exhibited SA colonization, including two meticillin resistant strains. Urine samples were positive in 30/323 patients (9.3%). Three patients presented an early OSI: two infections of a revision THA and one infection of a revision TKA. Two of these patients had an SA infection, including one who was colonized and had applied the chemical decontamination protocol before hospitalization. Discussion: By treating bacteriuria before hospitalization, deferral of the scheduled operations could be avoided. Laboratories must run two sets of tests to search for both met-S and met-R SA, which in our experience was not always the case despite written prescriptions. Implementation of chemical decontamination of the nasal passages and skin before surgery requires a well-established cooperation between the primary care physician and the hospital. The three infections recorded in this series involved revision procedures, with a context of rheumatoid polyarthritis for two patients. Conclusion: Systematic screening for SA colonization in orthopaedic surgery remains a subject of debate, particularly concerning the cost-efficacy balance, but can be quite useful in certain situations such as revision or prosthetic surgery in immunodepressed patients

Purpose of the study: We analysed the clinical and radiographic outcomes of 113 cemented total knee arthroplasties (TKA) with resurfaced patella implanted in 83 patients with rheumatoid arthritis who were reviewed 1 to 12 years after implantation. Mean follow-up was 5.86 years. All implants were posterior stabilised (HLS) implanted by one operator using the same procedure. Material and methods: One hundred seventy-two rheumatic arthritis patients underwent TKA from 1996 to 2007. At last follow-up, 68 could not be contacted, 11 had died, 9 declined review. The review was conducted in 2008 for 83 patients, 113 TKA. Female gender predominated (86.4%) and 29 patients (32.6%) had two TKA. Mean age at revision was 67.6 years. Results: Seventy patients (84.4%) were satisfied or very satisfied with their prosthesis. The knee score (IKS) improved from 31.58 (0–63) preoperatively to 86.21 (59–99) postoperatively; the function score (IKS) improved from 31.7 (0–100) preoperatively to 77.12 (0–100) postoperatively. The improvement was significant for both scores. Men preoperative flexion was 97 (35–125) versus 112.1 (30–130) postoperatively. Ten knees presented anterior pain at revision (8.8%). The postoperative femorotibial mechanical angle was 180.72 (173–192). The mean femoral mechanical angle was 91.3 (78–99); the mean tibial mechanical angle was 89.4 (52–110). Men postoperative patellar height was 0.79 (0.24–2) measured with the Blackburn index. The patella was centred for 87.6% (99 knees) and subluxated laterally for 12.1% (14 knees). There were no loosening. Two arthroplasties had to be revised surgically (1.8%): one for infection (two-phase replacement with a hinged prosthesis) and one for patellar fracture treat by osteosynthesis. Two patients developed a postoperative phlebitis (2.4%). Discussion: This study demonstrates the good mid-term outcomes achieved with a cemented posterior stabilised TKA in patients with rheumatoid arthritis. These results are nevertheless slightly less satisfactory than with TKA implanted for degenerative disease: this might be explained generally by disease-related impact on the functional result. Prosthetic surgery of the knee remains the treatment of choice for advanced arthritic degeneration

Surgical site infection (SSI) is an important outcome indicator. It is estimated that 70% of post-operative infections present after discharge. A reliable post-discharge surveillance (PDS) method is yet to be described. The aim of this prospective cohort study was to assess the reliability of patient self-diagnosis. Telephone questionnaires were used following hip and knee prosthetic surgery. A trained validation nurse checked the wounds of all patients reporting problems and a sample of those who did not. 376 elective hip and knee arthroplasty procedures from 363 patients were included. In-patient infection rate was 3.1% (13 of 422 procedures) and post-discharge infection rate was 5.2% (22 of 422 procedures). Results suggest that patients can reliably self diagnose SSI. The sensitivity of the procedure (the probability that the telephone surveillance will detect an infection given that the patients has an infection) was 90.9%. The specificity (the probability that the telephone surveillance will report no infection given that no infection is present) was 76.6%. Hence telephone PDS of SSI is a valuable means of identifying accurate rates of hospital acquired infection following surgery. In this study population, 41% of infections were diagnosed post discharge, which is lower than has previously been estimated. PDS of SSI is necessary if accurate rates of hospital acquired infection following surgery are to be available

Introduction: Surgical site infection is a growing and expensive complication. Surgical site surveillance is performed with the aid of laboratory tests and clinical evaluation; the latter has some limits, including reproducibility and validation of results and, as suggested by many authors, the need of a dedicated well trained staff. At present no imaging instruments are available for routine objective monitoring of “normal” or complicated surgical site healing. Recently, technological improvement made available for clinical use high resolution portable digital telethermocameras at relatively low-costs. No data are available in the literature, concerning the “physiological” thermographic pattern of surgical wounds in orthopaedics. The aim of this study is then to evaluate the physiological telethermographic pattern of surgical site healing after hip and knee prosthetic surgery, to provide a reference value for further analysis. Methods: The surgical site of 60 consecutive patients undergoing total hip replacement and 40 patients unde-going total knee replacements were examined at fixed intervals from the day before surgery to six weeks after intervention, using a portable telethermographic camera (AVIO TVS-200EX). Results were compared with contralateral side and with laboratory data. Results: A physiological “telethermographic pattern” of wound healing was observed and showed to be remarkably reproducible among different patients. A thermographic peak was observed at day 3, with a mean temperature elevation (hottest spot) of 2.3 +− 1.3 ^C after hip replacement and of 2.8 +− 1.5 ^C after total knee replacement. Similar results were obtained when considering the mean surface temperature in a 10 cm rectangle area identified around the surgical wound. Temperature at the surgical site slowly returned to baseline (contralateral side as reference) in a six weeks period. Discussion and Conclusion: Telethermography through a portable camera appears a reliable, not invasive, not irradiating and easy-to-use tool to monitor surgical site following hip or knee arthroplasty at the patient’s bed. Surgical site show a highly reproducible physiological thermographic pattern, with peak values at day 3 and a constant decrease until normal values at week 6 after surgery. This findings may be used as a reference for further studies, to establish the relevance of abnormal thermographic patterns in connection with surgical site complications

Culture of tissue samples obtained peri-operatively is ‘the gold standard’ for determining the presence of infection in prosthetic revision surgery. The growth of identical bacterial strains in three or more specimens strongly indicates an infected prosthesis. With routine microbiological culture techniques, identification of different phenotypes of coagulase negative staphylococcus (CNS) will be interpreted as either contamination or a polybacterial infection. At our clinic, different phenotypes of CNS are cultured in approximately 20% of patients operated with a two-stage revision due to a chronic prosthetic infection. We studied the genotype of different phenotypes of CNS cultured in specimens obtained from prosthetic joints. We analysed 22 cases, where different phenotypes of CNS were cultured in tissue, and joint fluid specimens were collected peri-operatively. The pre-operative diagnosis was chronic prosthetic infection (n=16), aseptic revision (n=5) and primary prosthesis (n=1). Different phenotypes were assessed by colony morphology and/or antibiogram. Pulsed-field gel electrophoresis (PFGE) was employed to identify and compare the genotypes. In 16 out of 22 cases (73 %), PFGE unveiled that phenotypically different strains of CNS belonged to the same genotype. Of these 16 cases 7 had different antibiograms. In the other group (6/22), phenotypically different strains of CNS did not belong to the same genotype. In the 16 cases with different phenotypes belonging to the same genotype, gentamicin bone cement had previously been used in 15 cases. In the other group (6/22), gentamicin bone cement had not been used previously in any case (p < 0.01, chi-square test). Phenotypically different strains of CNS identified by routine microbiological techniques should not be classified readily as contamination or as a mixed bacterial infection in prosthetic surgery. A particular precaution should be taken in the case of patients who had previously been operated on with use of gentamicin-loaded bone cement

Systematic and prospective collection of data (Registro degli Interventi di Protesi d’Anca – RIPA-L) on hip replacement operations is underway in the Lazio Region (Italy) as part of a multi-regional registry on orthopaedic prosthetic surgery. The project is partially funded by the Ministry of Health and includes five regions of Italy, coordinated by Istituti Ortopedici Rizzoli, Bologna, in co-operation with the Italian National Institute of Health. The aim of the project is to create – as a first attempt in Italy – a national database on hip replacement operations in order to monitor adverse events related to orthopaedic prostheses. First, in the Lazio region, standardised methods and data collection instruments were developed and assessed in a pilot study at three hospitals in Rome (teaching, public and private). The case report form (CRF) includes identification data, clinical findings, details of the operation (duration, grade of surgeon, and operative technique) and characteristics of the prosthesis. A web-based CRF facilitates data registration (. www.asplazio.it. ). Second, 32 orthopaedic centres agreed to participate in the initiative and started collecting data. Indeed, 53% of all hip replacement operations in the Lazio region are performed in these centres (n=6355, source: Regional Hospital Information System, 2003). RIPA-L represents an important instrument to monitor the quality of hip replacement surgery in the Lazio region and to collect information on types of orthopaedic prostheses, contributing to the national database and, more generally, promoting quality in orthopaedic surgery

Introduction and purpose: There has been a great increase in prosthetic surgery. The demand for homologous blood is higher than the supply in blood banks. We must bear in mind the adverse effects of homologous blood transfusion: incompatibility reactions, metabolic disorders, risk of disease transmission. There are alternatives to homologous blood: autotransfusion methods. Materials and methods: Knee prostheses were implanted in 60 patients between 2002 and 2003 using the CBCII Constavac Blood Conservation System and reinfusion of the harvested blood. We analysed epidemiological data, ASA, harvested blood volume, haematology values, need for homologous blood transfusion and complications. Results: 60 prostheses. Mean duration of surgery 121 minutes, mean hospital stay 8 days. 83.3% women, mean age 66.2 years. Harvested volume 677.5 ml (±221.3). Homologous transfusion was required in 9 cases. Haematocrit and haemoglobin tests were performed prior to surgery and at 24, 48 and 72 hours with the following results, respectively: 40.87, 13.4; 31.39, 10.4; 30.06, 10.05; 30.75, 10.2. Complications: fever (7), nausea (3). Conclusions: Autotransfusion reduces the need for homologous blood. Harvested blood is an excellent source of erythrocytes and platelets. There are few adverse effects if reinfusion takes place within 6 hours and the volume is not over 1,000 ml. The association of different autotransfusion techniques and other more recent ones such as EPO and intravenous iron could make transfusion of homologous blood unnecessary in over 90% of patients

Low virulent chronic prosthetic infection might be indistinguishable to aseptic loosening. Polymerase chain reaction (PCR) has been introduced to improve bacterial detection of implant infection. However, there is great risk of false positive results when using broad range/universal PCR primers. The source of DNA contaminants may be of environmental origin as well as the reagents employed. To study the presence of bacterial DNA in culture negative biopsy specimens by using defined criteria for PCR positivity. We included six specimens from each of 21 patients preoperatively considered having aseptic loosening of a hip prosthesis. These 126 specimens were culture negative after seven days of incubation. Prior to incubation, the specimens were divided, and half of each specimen was processed for PCR. Three sets of primer pairs targeting the 16S rRNA gene were developed. Nine specimens from culture proven prosthetic infections and nine specimens from primary prosthetic surgery served as positive and negative controls, respectively. A specimen was considered PCR positive if:. bacterial DNA ≥ 2 times than the reagent control, and. a positive PCR signal for ≥ 2 primer pairs. All the 126 patient specimens were PCR negative and the nine positive controls were positive. One of nine negative specimen controls was PCR positive, DNA sequencing demonstrated a non-pathogen. Five single PCR reactions (1.3 %) were positive. This study underlines the importance of establishing stringent criteria for interpretation of PCR positivity to apply to clinical specimens. By the criteria used, five single positive PCR reactions were identified as false positives. Positive PCR reactions in all of the specimen positive controls prove the detection ability of the method. One PCR positive result in a specimen negative control demonstrates the contamination risk in collection and handling of biopsies. In conclusion, by using a semiquantitative PCR and stringent criteria for PCR positivity we were unable to detect any infections missed by culture

Introduction: With the growing number of primary knee arthroplasties, the number of revision operations is also increasing. The large number of unicondylar replacements carried out in the 1980’s, due to lack of modern total condylar implants, grant the revision techniques an outstanding significance in Hungary. One of the main issues of modern revision techniques is the management of bone defects, which can be solved by different methods documented in literature. Aim of study: The aim of our study was to investigate the success and feasibility of the various defect management techniques by evaluating the results of revision knee prosthetic surgeries carried out at our clinic. Patients and methods: Femoral and tibial bone defects had to be solved with revision surgeries in 35 cases, all performed due to aseptic loosening of uni- and total condylar prostheses implanted earlier. For filling of bone defects, metal augmentation of the prostheses was applied in 9 cases, allografts from bone bank were used in 11 cases, own cancellous bone was applied in 20 cases. Results were prospectively analysed with the help of the knee society rating system, with an average follow-up of two and a half years. Results: Revision interventions were successful in 34 cases, detailed results are revealed in the presentation, complemented with case presentations. In a single case, repeated intervention surgery is indicated due to disorganisation of the structural allograft and the resulting loosening of the tibial component. Conclusion: The success of the various bone replacement techniques, completed with adequate indication could be proven in all cases. The unsuccessful case proved that allograft incorporation should be supported by appropriate stem augmentation of the tibial component. In order to perform successful revision knee arthroplasty, we consider it fundamentally important to have a wide variety of allografts from bone bank and a modern knee prostheses system application already during primary implantations

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Shoulder arthroplasty has been performed by many years for the treatment of several conditions such as osteoarthritis, umeral head avascular necrosis and proximal umeral fractures following traumas. Surgical site infection (SSI) following shoulder arthroplasty remains a challenge, which increases morbidity including reoperations, implant removal, poor mobility, and raises extra medical costs. Identification of risk factors may help implementing adequate strategies to prevent infection. We aim to identify pre- and intra-operative risk factors associated with deep infections in shoulder arthroplasty. An age and sex-matched case control study was conducted to describe the prevalence rate, clinical and microbiological findings and to evaluate patient and surgical risk factors for shoulder arthroplasty-associated infections (SAIs), among 158 patients who underwent shoulder replacement surgery due to any reason, from 1988 to 2011 at a tertiary public university institution. To evaluate risk factors from SAI we performed uni- and multivariate analysis by multiple logistic regression. We analyzed 168 prosthetic shoulder replacement surgeries from 158 patients, with an overall infection rate of 9.5%, (16/168 cases). Gram-positive cocci and Gran-negative bacilli were equally isolated in 50% of cases, however the most common bacteria detected (18.8%) was Pseudomonas aeruginosa. Univariate analysis identified neither specific comorbidity nor pre-operative risk factors, but American Society of Anesthesiologists (ASA) score higher than 2 (odds ratio [OR] = 5.30, 95% confidence interval [CI] = 1.58 to 17.79; p=0,013) to be significant preoperative patient-related predisposing factor for SAI. On univariate analysis, the only surgery-related factor significantly associated with higher risk of SAIs was the presence of surgical haematoma (OR = 7.1, 95% CI = 1.1 to 46; p=0.04). On multivariate analysis ASA score higher than two (OR = 4.7, 95% CI = 1.3 to 16.9; p=0.01) was the only independent predictor for periprosthetic shoulder infection. This study identified unusual pathogens and confirmed previously patient-related known factors such as higher ASA score that predispose to SAIs

Great diffusion of hip prosthetic surgery, in relatively-young patients too, generates as consequence an increase in prosthesis failures associated with limited or massive bone losses, making revision surgery mandatory, even in most advanced degrees of osteolysis. In best surgery strategy planning are essential: - evaluation of osteolysis degree with standard x-Rays; - evaluation of periprosthetic bone turn-over with scintigraphy (both a specific as they give merely qualitative evaluations of bone remodeling); – quantitative evaluation of periprosthetic bone mineral density with periprosthetic mineralometry (D.E.X.A.). Data obtained with these methods allow more accurate decisions, during the pre-operative phase, regarding the most indicated implant for revision surgery: mid or long-stem, with or without omoplastic transplants, with or without materials promoting bone rehabitation. In any case, the surgeon must have all possible solutions in order to eventually change the operative plan during surgical act. Following qualitative and quantitative periprosthetic bone evaluations, we use to classify stem and cup mobilizations with Italian Group for Revision (GIR) classification. According to GIR classification, our actual trends in the choice of revision prostheses, in the most advanced degrees of complex mobilizations of stem and cup, are the following: - GIR 3 (Enlargement of the femoral shaft with thinning of cortical bone and loosing of 2 or more walls; loosening and acetabular deformation with losing of one ore more columns and the bottom). In this degree we prefer a long-stem concept straight prosthesis; this prosthesis allows an immediately more stable implant, due to optimized length, in opposition to rotation forces and assuring force transfer in both proximal and distal direction. When osteolysis is wider, it was necessary a strategy change, searching a more distal locking of the implant, according to Wagner’s criteria. The SL Wagner’s prosthesis restores cohesion with the reabsorbed bone surface, generating a relative stability in the immediate post-op period; in the following 2 months, an intense bone apposition, which brings to a progressive filling of bone losses, takes place. For this purpose, it is not indicated, apart from surgical way used, cutting the muscle insertions around the thinned wall. This revision prosthesis is fixed without the use of cement due to the distal blocking, guaranteed by his conical shape; the stem is straight and it is not fit to the natural front-bending of femoral shaft. For this last explained reason, we follow these guidelines, improving our results, using a cementless anatomic modular stem: with this kind of implant design, that preserves cortical bone of femoral shaft from stress shielding, and the extremely wide (XX combination) choice of head and neck components, we are now able to regain as well as possible, the correct offset and center of rotation. For the acetabular loosening, we use to implant oval cups, that naturally fit the acetabular lesion, with or without bone grafts impaction in bone loss areas.- GIR 4 (Massive proximal bone loss all around the shaft; massive peri-acetabular loss). In the past we implanted wide-resection cemented (Muller) or non cemented (Kotz) prosthesis, originally designed for onchologic patients, to treat complete femoral osteolysis. The wide resection uncemented prosthesis, after follow up, supports the Wagner’s theory of distal support, because in spite of an almost complete bone sacrifice, there is an attempt of periprosthetic corticalization by the femoral bone. Since some years we implant even in this cases a modular distally-anatomic revision prosthesis, this type of prosthesis, thanks to his proximal component, provides a relative primary metaphyseal support, that improves global stability of implant. In massive peri-acetabular loss we prefer the use of oval components with peripheral supports and obturatory hook, with bone graft impaction. Only as “extrema ratio” we choose for the implant a McMinn stemmed cup. From these guidelines, integrated with clinical observation at mid range follow-up, appears clerarly that cementless prosthesis in hip revision surgery, even in most advanced degrees of osteolysis, are really able to guarantee good results for the patient. These patients, previously implanted with hip prosthesis, have intrinsic limitations of hip joint ROM, sometimes associated with muscular impairments; therefore it’s rarely possible to bring back the hip to an optimal degree of function, especially if compared with a normal joint. The goodness of long-term results must be therefore evaluated in relation to patient’s conditions before the operation itself, especially according to bone conditions regarding osteointegration of prosthesis. If follow up of patient is constant, allowing to program with good timing the revision surgery, if necessary, the use of cementless prostheses is a very powerful (nevertheless conservative) instrument for good functional recovery of these patients

Purpose of the study: Increasing the number of times the operating room doors open increases the number of airborne bacteria and consequently the rate of postoperative infections with sometimes disastrous results, particularly for prosthesis surgery. Material and methods: An observer counted the number of times the door to the operating room were opened during orthopaedic operations. The study was conducted in a teaching hospital (hospital A) during scoliosis surgery then repeated for a similar operation after posting dissuasive signs and delivery of information to the personnel concerning the risk of contaminating the patient. A study was then conducted for total hip arthroplasty (THA) in another teaching hospital (hospital B) and in a private clinic (hospital C). The same protocol as used in South Australia was applied for these studies. Results: The mean rate of door opening in hospital A was 0.52/min. This rate was 0.45/min (13.5% less) in the same hospital A after posting dissuasive signs on the doors and providing information to the personnel. In hospital B, the rate was 0.67/min. In hospital C, the rate was 0.42/min (i.e. 37% less). In Australia, the mean rate was 1/min in hospital A before sign posting and information delivery and 0.65 (−35%) after. In hospital B, the rate was 0.87/min and in hospital C 0.47/min (i.e. 46% less). Discussion: Nearly 50 years ago Sir John Charnley demonstrated that airborne contamination must be controlled in prosthetic orthopaedic surgery. In France airborne contamination is regulated by a series of standards (NF EN ISO 14644 established in 1999) and partially controlled during the design phase of operating rooms with the installation of laminar flow ventilation. Door opening, and particularly swinging doors, causes turbulent airflow increasing bacterial contamination. Conclusion: Circulation in the operating room should be limited to necessary organisation (prior transport of instruments and consumables, fluoroscope, nursing staff turnover, etc.) and by information and education of all participants. The presence of observers is inevitable in the operating rooms of teaching hospitals. Their entrance and exit should however be limited and their movement within the room controlled. It is also recommended to use cell phones

Introduction: Prosthetic Disc surgery is a rapidly growing field in patients with symptomatic degenerative disc disease. Few reports of long-term follow up are yet published, but several authors have published case series including reports of significant complications and difficulties with revision surgery. 1. Advocates of disc replacement surgery have claimed that Osteolysis, whilst being a potential problem associated with artificial disc replacement, has not yet been reported. 2. . Methods: We present what we believe is the first histologically proven case of significant Osteolysis associated with artificial disc replacement in the world literature. We also present a literature review of the laboratory research into performance of artificial disc replacement, focusing on wear debris and particle generation. Results: Our report involves a 42-year-old lady with degenerative disc disease who underwent L5/S1 anterior lumbar interbody fusion in July 1999, with a simultaneous L4/L5 Charite disc prosthesis. In May of 2002 she developed significant back pain, and further investigation, including biopsy revealed polymer disintegration and associated Osteolysis. Attempted revision surgery in May 2003, using a combined anterior approach by a vascular and spinal surgeon, led to damage to the adherent common iliac vessels and inferior vena cava, and the attempt to remove the prosthesis was abandoned. Histological samples taken at surgery confirmed the presence of polyethylene wear debris. Posterior instrumented fusion was performed in June 2003 and the patient made a successful recovery. Discussion: It is important in modern spinal practice to be fully aware of both reported and potential risks of the use of new prostheses. We report an important complication associated with the use of artificial disc replacement. Revision of such prostheses is challenging, and we advise a combined surgical approach

Introduction: Prosthetic disc surgery is a rapidly growing field in patients with symptomatic degenerative disc disease. Few reports of long-term follow up are yet published, but several authors have published case series including a report of significant complications and difficulties with revision surgery. 1. Advocates of disc replacement surgery have claimed that osteolysis, whilst being a potential problem associated with artificial disc replacement, has not yet been reported. Methods: The literature relating to the laboratory research into performance of artificial disc replacement, focusing on wear debris and particle generation is reviewed. Reports of complications are reviewed. A case of significant osteolysis associated with artificial disc replacement is reported. Results: Our report involves a 42-year-old lady with degenerative disc disease who underwent L5/S1 anterior lumbar interbody fusion in July 1999, with a simultaneous L4/L5 Charité disc prosthesis. In May of 2002 she developed significant back pain, and further investigation revealed polymer disintegration and associated osteolysis. Attempted revision surgery in May 2003, using a combined anterior approach by a vascular and spinal surgeon, led to damage to the adherent common iliac vessels and inferior vena cava, and the attempt to remove the prosthesis was abandoned. Histological samples taken at surgery confirmed the presence of polyethylene wear debris. Posterior instrumented fusion was performed in June 2003 and the patient made a successful recovery. Discussion: It is important in modern spinal practice to be fully aware of both reported and potential risks of the use of new prostheses. Wear of an artificial disc causing osteolysis is anticipated. This is believed to be the first case in the world literature of this important complication associated with the use of artificial disc replacement. Revision of disc prostheses with osteoly-sis is challenging, and a combined surgical approach is advised

Aim: To determine the surgical site infection (SSI) rates for prosthetic hip and knee replacement surgery. Materials and Methods: Between April 2002 and March 2003 the Infection Control team in conjunction with the Orthopaedic Department had participated in national surveillance project to determine the surgical site infection rates for prosthetic hip and knee replacement surgery. Information was collected relating to surgeon specific data and patient risk index. Each surgeon was given a unique confidential code and patients intrinsic risk of infection calculated based on ASA grade, wound class and the duration of surgery. Results: During the first year of surveillance 455 prosthetic hip replacements were undertaken (i.e. hemiarthroplasty, primary and revision surgery). A total of 12 patients were identified with an SSI giving an average of 2.6% compared with national figure of 3.0%. Out of this 25% (3) superficial and 75%(9) deep-seated infection with Methicillin Sensitive Staphylococcus Aureus (MSSA) and MRSA being the commonest organisms. 234 prosthetic knee replacements (Primary and Revisions) were carried out over the same period of time with 7 cases identified with SSI, an average incidence of 3% compared with national average of 1.6%. Three were superficial and four with deep infection with MRSA, MSSA and coagulase negative staphylococci being the commonest organisms. MRSA containment policy was introduced in November 2002 with pre operative screening,” ring fencing” orthopaedic patients and improved awareness of cross infection. Since then over the last 4 months of this study the incidence of SSI has fallen from 3.3% to 1.9% in prosthetic hip surgery and 5.8% to 0.7% in prosthetic knee surgery in comparison to previous quarter. Conclusion: Significant cost and morbidity are associated with infection of the prosthetic joint. With simple measures like improved awareness of cross infection among the staff and relatives, ”ring fencing” orthopaedic patients and pre operative screening surgical site infection rate can be reduced

Introduction: Antibiotic prophylaxis is a standard practice in prosthetic orthopaedic surgery. In total knee arthroplasty (TKA), several surgeons routinarily use a tourniquet to interrupt the blood circulation of the leg to be operated. The penetration of systemically given antibiotics is reduced by the tourniquet. To avoid this problem, some authors administered the antibiotic in a leg vein, after tourniquet inflation, to enhance antibiotic penetration in the operative field. We reviewed the available literature about the use of regional prophylaxis in TKA. Materials and methods: The medical literature was seeked by means of the PubMed (National Library of Medicine, Washington, USA) research engine. The keywords «prophylaxis», «knee» «arthroplasty», «regional» were used in various combinations. Results: In 1990, Hoddinott et Al. compared the bone and fat penetration of two cephalosporins (cefaman-dole and cefuroxime) given either by the systemic and the regional route, and found the concentrations after regional administration significantly higher. A similar result was confirmed by Field et Al. in 1992. In 1993, de Lalla et Al. compared the systemic administration of 800 mg teicoplanin with the regional administration of 400 mg teicoplanin, and found higher levels of drug in the tissues of the operative field after regional administration. In 2000, the same authors enrolled 205 prostheses in a clinical trial to assess the efficacy of the regional prophylaxis with 400 mg teicoplanin, and did not record any prosthetic infection. In 2001, Lazzarini et Al. reviewed 217 patients who received regional prophylaxis with 400 mg teicoplanin for TKA, and found 8 (2.9%) surgical site infections, mostly occurring in patients with previous TKA. In 2003, Lazzarini et Al. compared the tissue levels of teicoplanin after systemic administration of 800 mg and after the regional administration of 200 mg. The tissue levels after regional administration were still higher than those after systemic administration. Conclusion: There is a good evidence for the use of regional prophylaxis when a tourniquet is used for TKA

Purpose: Hip joint involvement is a frequent complication of Paget’s disease. We conducted a multicentric retrospective study to analyse perioperative problems and outcome after total hip arthroplasty in patients with Paget’s disease. Material and methods: Thirty-nine total hip arthroplasties were implanted between 1979 and 1998 in 35 patients with Paget’s disease of the hip (four bilateral cases). The series included 20 men and 15 women, mean age 74 years (55–86). The pre and postoperative status was evaluated with the Harris score and radiographically. We recorded operative time, blood loss, and events noted in the operative report. Among the 35 patients, 24 were retained for analysis (three deaths, eight lost to follow-up) at mean 62 months. Results: The mean preoperative Harris score was 46/100 (18–67). Eighteen patients had leg length discrepancy. Nine had permanent hip flexion associated with external rotation and seven had coxa vara. Twenty-nine patients were given anti-osteoclastic treatment preoperatively. We implanted 20 cemented cups and 19 press-fit cups. Thirty-one femoral stems were cemented and eight were not. On average, operative time was 130 minutes and blood loss was 830 cc. Difficult operative events involved luxation of the femoral head, remodelled sclerous bone (greater trochanter fractures, difficult reaming, narrow canal), cam effect related to bone hypertrophy and bleeding. Venous thrombosis occurred in four patients, pulmonary embolism in one, and one psoas haematoma. There were three luxations. At last follow-up (mean 71 months), the clinical outcome was excellent for 13 patients (48%), good for eight (29%), fair for two (7%) and poor for four (15%). Implants were cemented at the pelvis and femur level in three cases and noncemented in one. Discussion: Prosthetic hip surgery in patients with Paget’s disease is difficult and raises the risk of postoperative complications. Prior medical treatment is needed before surgery to limit the risk of bleeding. In our series, fixation modalities were very variable. Non-cemented implants on Paget’s diseased bone performed comparably with non-cemented implants

Purpose: Prosthetic hip surgery (150,000 total hip arthroplasties in France including 10–12% revision procedures) have required the development of bone banks to have graft material readily available. Safety and tracability requirements have led to the disappearance of local banks and the creation of validated tissue banks. The French tissue bank (TBF), which received its official authorization from the AFSSAPS in January 2001, began operating in 1992, collecting femoral heads (FH) procured during hip arthroplasties. Material and methods: Material collection has increased steadily over the last five years. In 2002, 5004 FH were collected in 126 public or private centres. The number of FH which were rejected for regulatory, health (clinical and biological selection) and harvesting quality remained relatively stable around 20% from 1997 to 2000. Rejection for socioclincal reasons, which varied from 3 to 5%, included, in decreasing order, cancer, transfusion history, systemic disease and/or history of neurodegenerative disease, long-term corticosteroid treatment, and notion of infectious risk (mainly viral). Secondary rejection because regulatory tests could not be performed varied from 3 to 6% and included haemolysis, insufficient quantity for assay or preservation in the serum bank, ALAT assay impossible, serology suggestive of recent or former viral infection: HCV, HBV, HIV, HTLV. The FH underwent chemical treatment (viral and prion inactivation), mechanical treatment (production of bone shreads, cancellous blocks, wedges, whole heads, heads without neck), radiosterilisation and lyophylisation. Results: Sixty percent of the grafts were used for hip arthroplasty, mainly during revision procedures (80%) (1.4 grafts on average, whole heads and blocks and more recently shredded bone); 8.5% were used for knee arthroplasty and 11.5% (blocks) for spinal surgery, 11% for fractures (in decreasing order femur, distal tibia, tibial plateau, ankle, foot, shoulder, arm, other), 4% for nonunions, 5% for osteotomies (blocks or wedges). Conclusion: More and more grafts are used for osteotomy and spinal fusion procedures. Use of shredded bone is increasing. We are currently working on a cancellous bone paste combined with bone substitute

Aim: To see the efficacy of white cell scan in the diagnosis of prosthetic joint infections. Materials and methods: A retrospective study was done from Jan 2001 to Dec 2003 on patients with suspected joint infections after prosthetic joint surgery that had white cell scans. 109 patients were identified. We excluded 13 patients due to lack of proper documentation. The case notes for clinical details, laboratory investigations, radiological investigations were reviewed for this purpose. All the patients who did not have intervention were followed for a year for signs of infection. Results: After exclusion, of 13 patients, 96 patients were taken into the study. Of these, 44 were males and 52 were females. The age range was from 53 years to 91 years with an average of 76 years. We identified 30 total hip replacements, 61 total knee replacements, 3 shoulder replacements and 2 hemi-arthroplasties. 77 of these were cemented and 19 uncemented. The scan was done on an average of 23 months, with a range of 4 months to 16 years after the surgery. The chief complaint was persistant pain at rest and walking in all patients.11 patients had swelling, 7 had redness. None of the patients had discharge. White cells were raised in 6, ESR was raised in 28, and CRP was raised in 15 patients. Antibiotics were started on clinical grounds in 10 patients of which 4 patients showed no response. Plain X-Rays suggested infection in 5 patients. White cell scan suggested infection in 26 patients. Irrespective of scan report, 28 patients were operated for symptoms. There was surgical evidence of infection in 11 patients and 17 had aseptic loosening. Of the 11 surgically confirmed cases of infection, white cell scan showed infection only in 7 patients. Infection +ve Infection –ve. Positive White Cell Scan 7 19. Negative White Cell Scan 5 65. The specificity of the WCS is 0.77 and sensitivity is 0.58. The positive predictive value is 0.36, and negative predictive value is 0.92. Conclusion: White cell scan has a good predictive value for exclusion of prosthetic joint infections it has high false positive rate. However caution must be excised in interpreting the negative scans. Persistent symptoms should not be ignored. We recognise that the limitation of our study is our small sample size

Objectives

Implant-related infection is one of the most devastating complications in orthopaedic surgery. Many surface and/or material modifications have been developed in order to minimise this problem; however, most of the in vitro studies did not evaluate bacterial adhesion in the presence of eukaryotic cells, as stated by the ‘race for the surface’ theory. Moreover, the adherence of numerous clinical strains with different initial concentrations has not been studied.

Aims

Our aim was to analyse the long-term functional outcome of two forms of surgical treatment for active patients aged > 70 years with a displaced intracapsular fracture of the femoral neck. Patients were randomised to be treated with either a hemiarthroplasty or a total hip arthroplasty (THA). The outcome five years post-operatively for this cohort has previously been reported. We present the outcome at 12 years post-operatively.

In this case study, we describe the clinical presentation and treatment of 36 patients with periosteal chondrosarcoma collected over a 59-year period by the archive of the Netherlands Committee on Bone Tumours. The demographics, clinical presentation, radiological features, treatment and follow-up are presented with the size, location, the histological grading of the tumour and the survival.

We found a slight predominance of men (61%), and a predilection for the distal femur (33%) and proximal humerus (33%). The metaphysis was the most common site (47%) and the most common presentation was with pain (44%). Half the tumours were classified histologically as grade 1. Pulmonary metastases were reported in one patient after an intra-lesional resection. A second patient died from local recurrence and possible pulmonary and skin metastases after an incomplete resection.

It is clearly important to make the diagnosis appropriately because an incomplete resection may result in local recurrence and metastatic spread. Staging for metastatic disease is recommended in grade II or III lesions.

These patients should be managed with a contrast-enhanced MRI of the tumour and histological confirmation by biopsy, followed by en-bloc excision.

Cite this article: Bone Joint J 2014;96-B:823–8.

The credibility and creativity of an author may be gauged by the number of scientific papers he or she has published, as well as the frequency of citations of a particular paper reflecting the impact of the data on the area of practice. The object of this study was to identify and analyse the qualities of the top 100 cited papers in orthopaedic surgery. The database of the Science Citation Index of the Institute for Scientific Information (1945 to 2008) was used. A total of 1490 papers were cited more than 100 times, with the top 100 being subjected to further analysis. The majority originated in the United States, followed by the United Kingdom. The top 100 papers were published in seven specific orthopaedic journals.

Analysis of the most-cited orthopaedic papers allows us a unique insight into the qualitites, characteristics and clinical innovations required for a paper to attain ‘classic’ status.

The aim of this study was to analyse the functional outcome after a displaced intracapsular fracture of the femoral neck in active patients aged over 70 years without osteoarthritis or rheumatoid arthritis of the hip, randomised to receive either a hemiarthroplasty or a total hip replacement (THR). We studied 252 patients of whom 47 (19%) were men, with a mean age of 81.1 years (70.2 to 95.6). They were randomly allocated to be treated with either a cemented hemiarthroplasty (137 patients) or cemented THR (115 patients). At one- and five-year follow-up no differences were observed in the modified Harris hip score, revision rate of the prosthesis, local and general complications, or mortality. The intra-operative blood loss was lower in the hemiarthroplasty group (7% > 500 ml) than in the THR group (26% > 500 ml) and the duration of surgery was longer in the THR group (28% > 1.5 hours versus 12% > 1.5 hours). There were no dislocations of any bipolar hemiarthroplasty and eight dislocations of a THR during follow-up.

Because of a higher intra-operative blood loss (p < 0.001), an increased duration of the operation (p < 0.001) and a higher number of early and late dislocations (p = 0.002), we do not recommend THR as the treatment of choice in patients aged ≥ 70 years with a fracture of the femoral neck in the absence of advanced radiological osteoarthritis or rheumatoid arthritis of the hip.

We studied retrospectively the results of revision arthroplasty of the elbow using a linked Coonrad-Morrey implant in 23 patients (24 elbows) after a mean follow-up period of 55 months. According to the Mayo Elbow Performance Score, 19 elbows were satisfactory, nine were excellent and ten good. The median total score had improved from 35 points (20 to 75) before the primary arthroplasty to 85 points (40 to 100) at the latest follow-up. There was a marked relief of pain, but the range of movement showed no overall improvement. Two patients had a second revision because of infection and two for aseptic loosening. The estimated five-year survival rate of the prosthesis was 83.1% (95% confidence interval 61.1 to 93.3). Revision elbow arthroplasty using the Coonrad-Morrey implant provided satisfactory results but with complications occurring in 13 cases.

We wished to estimate the incidence of surgical-site infection (SSI) after total hip replacement (THR) and hemiarthroplasty and its strength of association with major risk factors. The SSI surveillance service prospectively gathered clinical, operative and infection data on inpatients from 102 hospitals in England during a four-year period.

The overall incidence of SSI was 2.23% for 16 291 THRs, 4.97% for 5769 hemiarthroplasty procedures, 3.68% for 2550 revision THRs and 7.6% for 198 revision hemiarthroplasties. Staphylococcus aureus was identified in 50% of SSIs; 59% of these isolates were methicillin-resistant (MRSA). In the single variable analysis of THRs, age, female gender, American Society of Anesthesiologists (ASA) score, body mass index, trauma, duration of operation and pre-operative stay were significantly associated with the risk of SSI (p < 0.05). For hemiarthroplasty, the ASA score and age were significant factors. In revision THRs male gender, ASA score, trauma, wound class, duration of operation and pre-operative stay were significant risk factors. The median time to detection of SSI was eight days for superficial incisional, 11 days for deep incisional and 11 days for joint/bone infections. For each procedure the mean length of stay doubled for patients with SSI. The multivariate analysis identified age group, trauma, duration of operation and ASA score as significant, independent risk factors for SSI. There was significant interhospital variation in the rates of SSI. MRSA was the most common pathogen to cause SSI in hip arthroplasty, especially in patients undergoing hemiarthroplasty, but coagulase-negative Staph. aureus may be more important in deep infections involving the joint.