Introduction. Septic arthritis of the hip in the newborn baby can result in severe long term sequelae in the form of dislocation of the hip, loss of movement and growth disturbance with leg length discrepancy. Reconstructive procedures for this difficult problem have not been satisfactory. Patient and methods. This series comprises eight patients with septic hip sequelae . All of them had old septic hip and leg length discrepancy ranging from 4 cm to 15 cm. all underwent hip stabilization by pelvic support osteotomy and simultaneous limb lengthening and angular deformities correction using the Ilizarov frame. The age at the operation range from 8 years to 19 years, with an average follow up 4 years. Results. The average of limb lengthening gained was 9cm. All hips remain stable and loss of the range of hip and knee motion was not significant. Other complications include pin tract infection one delayed consolidation of callus and one fracture of callus. Conclusion. The Ilizarov hip reconstruction is a good option for the treatment of the late sequelae of infantile hip infection in adolescents. It should be considered a promising choice for the management of late sequelae of infantile hip infection

Purpose. We analyzed a consecutive series of 36 total hip arthroplasties using cementless conical stem with a shortening osteotomy combined with greater trochanter transfer in cases with a high dislocated hip. Material and Methods. The causes of total hip arthroplasty were the sequelae of a septic hip in 20 cases and developmental dysplasia of the hip (DDH) in 16 cases. Mean patient age was 43.4 and the mean follow-up period was 3.3 years. We compared perioperative parameters, clinical, radiological results and complications between the two groups. Results. Mean Harris hip score improved from 42.4 to 84.2 in septic hip group and from 46.3 to 85.0 in DDH group. The mean leg lengthening and time to greater trochanter union was 36.5 mm, 3.7 months in septic hip group and 38.6 mm, 3.5 months in DDH group. Conclusions. Total hip arthroplasty using subtrochanteric osteotomy produced satisfactory clinical and radiological results and there is no significant difference between the two groups

Patients with a history of septic arthritis or tuberculosis (TB) of the hip frequently develop secondary osteoarthritis (OA). These patients present a challenge for having joint replacement because of abnormal bone development, the possibility of re-infection, soft tissue problems and their life-style (more active than patients with old age arthritis). We retrospectively review a decent group of 55 cases where one stage cemented total hip arthroplasty was performed with history of old hip infection by a team of surgeons at Wrightington Hospital, Lancashire, UK from 1970 to 2008. The purpose of this study is to find the survival analysis with revision (for infection) as the end stage. There are 33 females and 22 males aged from 25 to 75 yrs (mean 52 years). 21 patients had proven or probable tuberculous infection, 29 had the past history of old septic hip, and the remaining 5 had recent septic hip (i.e., less than 5 years). The patients are followed for between 1 to 23 years (mean 10 years). Pre-operatively, 25 patients had arthrodesis while 24 patients had moderate to severe secondary OA. 3 patients had dysplastic acetabulum, 2 patients had shallow acetabulum and 1 had Avascular Necrosis (AVN). In 33 cases, intra-operative tissue samples didn’t grow any organism, 2 samples grew Staphylococcus aureus, 2 samples grew Coagulase Negative Staphylococcus (CNS), 1 grew pseudomonas, samples were not sent in 9 cases, laboratory did not process the sample in 1 case and no documentation found in 3 cases. Cement with antibiotics was used in 45 patients (Gentamicin alone in 37 cases, Gentamicin and Vancomycin in 3 cases, Gentamicin, Fucidic Acid and Eryth-romycin in 2 patients, Gentamicin, Vacncomycin and Streptomycin in 1 patient, Gentamicin and Streptomycin in 1 case and Gentamicin, Vacncomycin and Amoxycillin in 1 patient). Mostly intravenous antibiotics (3 doses of Cefuroxime) were given, but in few cases with old TB, anti-tuberculous treatment was started pre-operatively and continued for 3 months post-op. In 16 patients either antibiotics were not given or not documented to be given. Failure happened in 2 cases of positive intra-op sample culture with Staphylococcus aureus, 1 patient with pre-op aspiration which showed pseudomonas and in 2 cases where tissue sample showed no growth. 8 patients had revision of at least one of the components for aseptic loosening. The 2 failed cases with positive culture with Staphylococcus aureus had post operative antibiotics and extra antibiotics in cement. Both cases had early wound healing issues. Conclusion: We can conclude that total hip arthroplasty is safe in old cases of septic or tuberculous hips, provided appropriate antibiotic cover. We have some evidence that total hip replacement can be carried out in cases of recent infection of hip but level of evidence is not very great as we don’t have a large sample of such patients

Background: Childhood septic hip should usually be treated immediately by arthrotomy and antibiotic. Even if treated correctly, the affected hip may become osteoarthritic and functionally disabling. Usually the literature is not in favor of THA in young patients, and the reports are on patients older than 32 years of age. Aims: We present here a unique group of very young patients who suffered from early coxarthrosis due to septic hip in childhood, with an average age of 19.14 years at the time of the arthroplasty. Methods: Seven patients who suffered from early coxarthrosis due to septic hip in childhood underwent total hip arthroplasty, with an average age of 19.14 years (range between 14 and 25 years) at the time of the arthroplasty. Results: The Harris Hip Score (HHS) improved from a pre-operative mean of 58.43 to a post-operative mean of 94.14. The follow-up period ranged between 2 and 25 years, with an average of 8.14 years. Conclusion: We conclude that THA in young people with early coxarthrosis due to septic hip in childhood provides good functional results

This study was undertaken to assess the feasibility of a new subtrochanteric osteotomy technique for total hip arthroplasty (THA) in cases with a high dislocated hip secondary to the sequelae of a septic hip in childhood. Eighteen patients (20 hips), aged 25 to 65 years (average 47.3 years), underwent THA using a cement-less conical stem (Cone prosthesis. ®. ; Protek AG, Berne, Switzerland) with a new subtrochanteric osteotomy technique and were followed for an average of 23.6 months. All patients were graded as type III (high dislocation) according to the Hartofilakidis classification, and according to the Crowe classification 3 cases were of type III and 17 were of type IV. The procedure was performed through a posterolateral approach and a provisional osteotomy was usually performed at the inferior half of the lesser trochanter. All acetabular component was inserted at the true acetabular and the acetabular cup was inserted in 5 cases and only a liner was inserted after cementing in 15 cases. The stem size and the amount of stem insertion was decided according to the preoperative planning and soft tissue tension. After final reduction, the greater trochanter was re-attached to the proximal femur with the hip in the abducted position. Cables or a grip system (Dall Miles. ®. , Stryker Orthopaedics Inc., Mahwah, NJ, USA) were used for fixation, and if possible, additional screws were inserted. Postoperatively, range of motion exercises were encouraged after 2 to 3 weeks of bed rest and non-weight bearing crutch ambulation followed. Weight bearing was permitted only after obtaining radiological confirmation of bone union, but then active exercises were strongly encouraged to stretch abductors. Mean duration of surgery was 180.6 minutes, and mean perioperative blood loss was 1424.1ml. There were no intra-operative complications. Post-operative dislocation occurred in 2 cases and partial femoral nerve palsy developed in 1 case. Mean Harris Hip Score improved from 42.4 to 84.2. Mean lateral opening angle of acetabular cup and liner was 34.7 0 and mean anteversion was 20.8 0. All femoral components were implanted in neutral to 5 degrees of valgus, and mean leg lengthening was 36.5mm. The mean time to greater trochanter union was 3.72 months. Primary THA in highly dislocated hips due to the sequelae of septic hip in childhood using the described subtrochanteric osteotomy and a cone prosthesis was found to be safe and effective at restoring leg length and trochanteric rotation. But more follow-up is required to more comprehensively establish the long-term results of the described procedure

Introduction and objective: Infection is one of the greatest threats in hip surgery. It is agreed that the implant should be removed. The debate remains open if one or two stage surgery is perferable. This study evaluates the two stage septic hip revison arthroplasty and compares our results with the literature. Materials and Methods: A retrospective clinical and radiological study was performed on patients that had a two stage septic revision hip surgery. The Harris Hip Score (HHS) and the Mayo Hip Score (MHS) were applied. The ASA-Score for evaluation of preoperative morbidity was introduced. Statistical evaluation included the t–test. Results: 40 patients with 41 primary total hip replacements underwent septic revision. 17 patients with 18 hip prostheses (8 male, 9 female) could be evaluated. 14 patients were deceased, the rest was unable to participate due to severe health problems.12 patientswith 13 hips had a primary reimplantation, 5 patients had to be left with a Girdlestone situation. The mean follow up was 52 months (4.3 years, standard error +/−28). The average age was 68 years. The mean preoperative ASA-Score was 3.24 (+/−0,75). Staph. aureus was the most common infectious agent (35%) followed by Staph epidermidis (24%) and E. coli (12%). The mean time between removal and re-implantation was 158 days. The most frequent primary preoperative indication for hip arthroplasty was osteoarthritis (62%) followed by trauma (24%) and avascular necorsis of the femoral head (14%). In 42%, the onset of ionfection was early (under 12 months after implantation), 58%% of the patients had a late onset infection. The MHS in the group who had a reimplantation was an average of 66/standard error +/−21). The patients with a Girdlestone situation had a HHS that was not significantly lower than the rest (58 in Girdlestone patients, 61 in patients with re-implantation). Discussion: The study demonstrated that our results compare well to those of other studies. It supports the conclusion that two stage septic hip arthroplasty is still an excellent option in septic revision arthroplasty. The preoperative ASA-Score which is not routinely mentioned in other studies showed that many of our patients were critically ill. This may explain the long interval between removal and reimplantation, and it may also be of value to determine wether to re-implant at all costs. This study remarkably demonstrated that patients with resection arthroplasty did not have a significantly lower HHS than those with performed re-implantation. The resection arthroplasty may be considered a valuable solution in clinically very ill patients according to our results. If a second operation considering the ASA -score would be too risky it should be discussed if reimplantation must be achieved

Aim

Due to medical and organizational factors, it occurs in everyday practice that spacers are left in place longer than originally planned during a two-stage prosthesis exchange in the case of prosthetic joint infections. Patients are severely restricted in their mobility and, after initial antibiotic administration, the spacer itself only acts as a foreign body. The aim of this study is to analyze whether the duration of the spacer in situ has an influence on the long-term success of treatment and mortality.

Reasons for bone loss in septic hip prosthesis include osteolysis caused by the infection in itself and by the mechanical loosening, while implant removal and the necessary bone debridment usually ends in a even more severe bone loss. In two stage revision surgery the use of a long stem antibiotic-loaded pre-formed cement spacer (Spacer G – Tecres s.r.l., Italy) appears particularly useful to allow mechanical stability and antibiotic local elution even in the presence of wide proximal femoral bone loss. After two months the revision is performed with non-cemented long stem modular implants (Profemur – Wright-Cremascoli) without the need for massive bone grafts. Recently we have also started using growth factors to stimulate bone stock reconstitution. In all the patients a double antibiotic therapy is administered after the first and second stage procedures for 6–8 weeks. The results obtained (54 patients, follow-up 2 – 5 years) according to this protocol show the absence of infection recurrence, 10 cranial spacer dislocation, not treated, 2 revision prosthesis dislocations, that required open reduction, 1 transient femoral nerve palsy. The described technique, used according to a proper protocol, allows to obtain good results, in the medium term follow-up

Introduction. Antibiotic loaded polymethyle methacrylate spacers are commonly used in the management of septic hip replacements. Aim. The aim of this study was to determine wear patterns on the articulating surfaces of these spacers, as well as to determine the extent of PMMA particulate debris generation. Method. We took tissue specimens around the acetabulae in 12 cases at the time of the second stage procedure for septic total hip revisions. These were subjected to histological analysis to determine the extent of PMMA particulate debris contamination. We also performed a basic explant retrieval analysis of the articulating surfaces of the PMMA spacers to determine any specific wear patterns. Results. We found numerous PMMA particles in the acetabular soft tissues biopsied. The particle concentration was highest in the area of the acetabular fovea. We could also demonstrate specific wear patterns on the spacers that could be correlated with the generally mismatched articulating couple between the spacer and the bony acetabulum. We could also demonstrate some boney destruction present in the acetabulum with long-term spacer use. Conclusions. We concluded that significant amounts of PMMA particulate debris are generated by these articulating antibiotic spacers. The total volume of this debris may be determined by specific wear patterns on the spacers’ surfaces. We recommend a thorough debridement to decrease the PMMA particle load generated. Consideration in respect of the bearing surface implanted after the explantation of the PMMA spacer should take into account the effect of the debris on the bearing surfaces. We also make recommendations in respect of the design of these PMMA spacers

Aim

Traditionally, serum white blood count (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been utilized as markers to evaluate septic arthritis (SA). Recently, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been identified as prognostic factors for treatment failure, mortality and morbidity in various clinical settings. To date, these markers have not been utilized for evaluating outcomes after hip and knee SA.

Thus, the purpose of this study was to determine the ability of admission NLR and PLR to predict treatment failure and postoperative 90-day mortality in hip and knee SA.

Introduction: Hip replacement prosthesis infection is a severe complication of ever increasing incidence. Currently there is controversy as to whether prosthetic revision surgery should be carried out in one or two stages and whether cemented or uncemented prostheses should be used.

Materials and methods: This is a retrospective study of 17 cases of chronic infections of hip replacements that were revised in one-stage procedures between 1996 and 2005 in our center. Mean follow-up is 3.4 years. We analyzed the functional status of the hips before and after revision using the Merle D’Aubigne scale, x-rays, and supplementary tests for diagnosis and decisions on treatment.

Results: The functional score at the end of the follow-up was 16.17 (Merle D’Aubigne scale). The most common pathogen is coagulase-negative staphylococci. Acute phase reactive elements reached normal levels. X-ray control does not show any alterations or signs of loosening. No subsequent revisions have been performed.

Conclusions: The diagnosis and treatment of prosthetic revision requires correct preoperative assessment and planning. Differential diagnosis of aseptic versus septic loosening in chronic infections is complex; in some cases it is necessary to wait for definite culture results for a surefire diagnosis. We think that in selected chronic cases of septic loosening of the hip due no non-multi-resistant organisms, one-stage revision using a Wagner osteotomy for diaphyseal cleaning combined with a hydoxyapatite-coated stem makes it possible to achieve good functional results and control infection, decreasing the morbidity and cost of a two-stage revision.

Since July 1996, we have treated 97 patients who developed sepsis following total knee arthroplasty and 53 who developed sepsis following total hip arthroplasty. We evaluated the rate of retention of prosthesis.

In 69 A-host patients, 80 B-host and 1 C-host, we identified 70 cases of Staphylococcus aureus, 76 of Staphylococcus epidermidis, 33 of Pseudomonas, 23 of Escherichia coli and 18 of Enterococcus. Five patients were diabetic.

Muscle flaps were used in 51 cases. Of the 131 patients available for follow-up, 94 healed with retention of prosthesis. Five patients had to undergo amputation. We are still treating 36 patients, some of whom have received a temporary prosthesis.

Most patients could be salvaged with a two-staged revision. Host status influenced outcome.

Infection of total hip replacement still is considered a devastating complication. One-stage revision, meaning complete removal of the implant and thorough debridement of the site together with the insertion of a new prosthesis during the same operation, is desirable because of improved rehabilitation of the patient and reduced costs. Although this method is known since more than 30 years it is not used widely yet because of several related risks: known methods rely on the use of antibiotic-loaded cement, which often has shown insufficient release of the added antibiotic. The carrier may even act as a bed for colonisation with selected bacteria. Osseous conditions presented during revisions prevent interconnection of the cement with the sclerotic bone. The toxic monomers of PMMA and heating during polymerisation causes necroses which may be origin of repeated loosening and new growth of bacteria. Filling the defects with cement provides unfavourable conditions in case of another revision, which has to be expected at a high percentage. To overcome these disadvantages uncemented techniques seem to be favourable.

After removal of the implants debridement is performed as in conventional septic surgery. After thorough cleaning and rinsing, bone voids are filled with bone graft using an impaction technique. We use allograft or xenograft bone that is free from antigenic material but intact structures of bone concerning collagen and mineral content. The bone is impregnated with high loads of antibiotic, using a specific incubation technique. There are two options of antibiotic impregnation: vancomycin (“V”) or tobramycin (“T”), the choice being dependent on the causative pathogen isolated. Combinations are possible in cases of mixed infections. The impregnation procedure guarantees high levels of antibiotics at the grafting site for several weeks during which the antibiotic is released into the surroundings. Systemic drug levels are usually undetectable. At the acetabular site we take care that the ground be sufficiently filled with antibiotic graft. Preferably an uncemented cup of hemispherical design is inserted. At the femoral site we prefer implants with a rectangular diameter. This design enables stable press fit contact with the shaft medially and laterally and leaves enough space for graft impaction at the posterior and anterior aspect of the endoprosthesis. Wounds are drained and closed immediately; rehabilitation is performed as after non-septic surgery.

Between 1998 and 2004 thirty-seven patients have been revised because of culture-proven infection of hip endoprosthesis. Causative pathogens were Coag.neg. staph (18x), S.aureus (11x), MRSA (4x), enterococci (9x) and other gram-positive pathogens (3x). In 6 hips gram-negative germs were found additionally. All hips could be followed up with a minimum of 2 years and a maximum of 8 years (mean: 4.1 years).

Wound healing was uneventful in all cases. Mean hospital stay was 16 days (10–32 days). Rehabilitation was in the range of uncomplicated primary THR in cases with short history of infection (up to 3 months) and prolonged in relation to duration of infection and amount of preceding surgery. In three hips there was recurrence of the infection, diagnosed between 6 and 12 weeks after surgery. In one of them the well-fixed stem had not been exchanged, in another one a technical error had occurred during impregnation of the bone graft. This one could be successfully re-operated using the same technique with appropriately impregnated bone graft, the other two were converted to a girdlestone situation. All other 32 hips showed no sign of infection until the last follow-up.

Bone processed in an adequate way represents an excellent carrier for vancomycin and tobramycin. With antibiotic graft compound eradication of pathogens, grafting of bony defects and re-insertion of an uncemented prosthesis may be accomplished in a single operation, making it an ideal tool in one stage non-cemented revision for infected total hip replacement. However, principles of septic surgery need to be observed. We now recommend removing even well-fixed prostheses and taking care, that we implant at least 50cc of well impregnated bone graft. Since the graft gradually is replaced by healthy own bone, improved conditions may be expected even in the case of another revision.

Aims: Infection of total hip replacement still is considered a devastating complication. One stage revision, meaning removal of implant and debris together with insertion of a new prosthesis during the same operation, reduces rehabilitation time and costs. To overcome the disadvantages of using cement, uncemented techniques seem to be favourable.

Methods: After removal of the implants debridement is performed as in conventional septic surgery. After thorough cleaning and rinsing, bone voids are filled with bone graft using an impaction technique. We use cancellous bone that is free from antigenic material but intact structures concerning collagen and mineral content. The bone is impregnated with high loads of antibiotic, using a proprietory incubation technique. There are two options of antibiotic impregnation: vancomycin or tobramycin. The impregnation procedure guarantees high levels of antibiotics at the grafting site for several weeks during which the antibiotic is released into the surrounding. Systemic drug levels usually are undetectable. Consequently an uncemented prosthesis is inserted. Wounds are drained and closed immediately, rehabilitation is performed as after non-septic surgery.

Between 1996 and 2003 35 patients have been revised because of culture proven infection of a hip endoprostheses. All hips could be followed with a minimum of 3months and a maximum of 6years.

Results: Wound healing was uneventful in all cases. Mean hospital stay was 16days (10–32days). In three hips there was recurrence of the infection, diagnosed between 6 and 12 weeks after surgery. One could be successfully re-operated using the same technique, the other two were converted to a girdlestone situation. All other 32 hips showed no sign of infection until the last follow up.

Conclusion: One stage non-cemented revision may provide an excellent solution for infected total hip replacement. However, several principles need to be observed. Bone processed in an adequate way represents an excellent carrier for vancomycin and tobramycin. Using an antibiotic graft compound 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 conditions may be expected even in the case of another revision.

Two-stage revision arthroplasty is the gold standard for treatment of infection after total hip Arthroplasty and end stage septic arthritis of the hip. In the first stage we used a modified technique to insert an inexpensive modular femoral component coated with antibiotic-impregnated polymethylmethacrylate articulating with a polyethylene liner. The construct was used in 8 patients with infected arthroplasty, and 6 patients with septic arthritis of the hip. Two patients were excluded (no second stage). Of the remaining 12 patients, only one patient had persistent infection after the first stage; 11 patients received a successful re-implantation at the second-stage. The technique provide a construct that can be used safely and successfully in the awaiting period between the two stages of revision arthroplasty.

Introduction: Septic total hip arthroplasty is a devastating complication. Most treatment protocols for infection of more than 2 – 3 weeks duration recommend removal of the prosthesis and cement followed by 4 – 6 weeks of IV antibiotics. Results using an antibiotic spacer to allow mobility of the patient and local antibiotic deliverance by elution from the spacer are reported. Methods: Since January of 1994, antibiotic spacers have been used as adjunctive treatment along with IV antibiotics and prosthetic resection in 18 septic total hips. The spacer is fashioned intraoperatively using a femoral Rush Rod as reinforcement. Antibiotics are chosen based upon either a previous hip aspiration result or empirically chosen on intraoperative gram stain results. Results: Fifteen patients have been reimplanted and are, to date, apparently free of infection. The average time to reimplantation was approximately 8 weeks (range: 4 to 24 weeks). Two patients were unable to be reimplanted due to persistent infection and currently have resection arthroplasties. One patient died prior to reimplantation. Discussion and conclusions: The use of a spacer has allowed the mobilization of the patient in a manner similar to a total hip arthroplasty while keeping the patient’s leg length approximately the same. Reimplantation is less traumatic for the surgeon as well as the patient and allows for the local deliverance of antibiotics to the tissues similar to the use of antibiotic beads. The authors believe the use of an antibiotic spacer in the treatment of septic total hip has been extremely useful in these difficult cases

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty.

Aims. Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique. Methods. We have analyzed patients undergoing this cement-in-cement technique for femoral revision in infection, and present a consecutive series of 89 patients. Follow-up was undertaken at a mean of 56.5 months (24.0 to 134.7) for the surviving cases. Results. Seven patients (7.9%) required further revision for infection. Ten patients died of causes unrelated to their infection before their two-year review (mean 5.9 months; 0.9 to 18.6). One patient was lost to follow-up at five months after surgery, and two patients died of causes unrelated to their hip shortly after their two-year review was due without attending. Of the remaining patients, 69 remained infection-free at final review. Radiological review confirms the mechanical success of the procedure as previously described in aseptic revision, and postoperative Oxford Hip Scores suggest satisfactory functional outcomes. Conclusion. In conclusion, we found that retaining a well-fixed femoral cement mantle in the presence of infection and undertaking a cement-in-cement revision was successful in 82 of the patients (92.1%) in our series of 89, both in terms of eradication of infection and component fixation. These results are comparable to other more invasive techniques and offer significant potential benefits to the patient. Cite this article: Bone Joint J 2022;104-B(2):212–220

Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision necessitate removal of all bone cement from the femur. In our two institutions, we have been using a cement-in-cement technique, leaving the distal femoral cement in selected cases for septic hip revision surgery. Between February 2010 and September 2019, 89 patients with prosthetic hip infection underwent first or single stage procedures leaving the distal femoral cement in situ and performing a cement-in-cement revision. The mean patient age was 72.0 years (24–92). The median time from the last arthroplasty procedure was 29.0 months (1–294). 81 patients underwent revision using a cemented Exeter stem, 7 patients received an articulating spacer, and one patient underwent excision arthroplasty with the distal cement left in situ. Patients received clinical and radiographic follow-up with a mean of 42.8 months (range 11.0–120.1 months). Oxford hip scores were collected from each institution's existing databases. 9 patients (10.1%) died within one year of surgery. No deaths were directly related to joint infection or the surgery. One patient was lost to follow up before one year. Of the remainder, 7 patients (8.9%) required further procedures for infection and were therefore considered to be treatment failures. 6 patients (7.6%) underwent planned second stage procedures with no recurrence of infection. 7 patients (8.9%) had further surgery for non-infective reasons. The Kaplan-Meier estimate of infection free survival at one year was 93.7% (95% CI 88.4 to 99.0%). No patients underwent revision for stem loosening. Oxford hip scores were available at over one year postoperatively for 51 patients with a mean score of 30.6, and a mean gain of 11.9. In our combined cohort of patients, cement-in-cement revision had an infection eradication rate of 91.1%. Patient selection is crucial, and the procedure can only be performed when there is a well-fixed cement mantle. However, when strict criteria are followed, this technique offers potential significant benefits to surgeons performing this challenging surgery, and more importantly the patients undergoing them

Background. The patients with high hip dislocation due to the sequelae of septic hip or neglected Developmental Dysplasia of the Hip (DDH) show severely impaired gait pattern. Total hip arthroplasty (THA) for these patients are expected to restore gait pattern by establishing better joint stability and biomechanics. To our knowledge, no study have investigated about objective change in gait parameters after total hip arthroplasty (THA) for these patients. So, we are to prospectively evaluate change in gait patterns after THA. Methods. Between 2012 and 2013, 11 patients with highly dislocated hip underwent unilateral THA with subtrochanteric osteotomy. There was 6 patients with DDH sequelae and 5 patients with septic hip sequelae. Spatio-temporal gait analysis was performed preoperatively and at 12 months after THA. We followed the patient 3, 6, 12 months and then annually postoperatively. The gait patterns were analyzed by several parameters such as cadence, speed, stride length, step length, step time, initial double support (IDS), terminal double support (TDS), stance phase and swing phase by a three-dimensional (3D) high-speed motion-capturing system (eight Eagle® cameras; Motion Analysis, Santa Rosa, CA, USA). Also dynamic range of motion (ROM) of hip joint and ground-reaction forces (GFR) were recorded. Clinical outcome was evaluated by using the Harris Hip Score (HHS). Radiographic assessments were evaluated for the changes in leg length discrepancy (LLD). Results. For operated limb, the mean period of TDS significantly increased from 8.6 % to 11.3 % respectively (p=0.038). As IDS, single support and TDS improved, mean period of stance phase increased from 54.4 % to 60.1 % of gait cycle and swing phase was relatively reduced from 45.4% to 39.9% (p=0.005) On the other hand, there were decrease in cadence, speed, step length on the affected limb postoperatively (p>0.05). In force graph, all patients showed significant increase of the peak force postoperatively. The first peak force (Fz1) was improved from 0.76 N (0.60 – 0.98) to 0.95 N (0.79 – 1.16) (p=0.007). The second peak force (Fz2) was improved from 0.70 N (0.44–0.96) to 0.94 N (0.85 – 1.14) (p=0.007). For the dynamic ROM, there were increase in sagittal plane motion and decrease in transverse and coronal plane. All of the changes were significantly not difference than preoperatively. Clinically, mean HHS was improved from 57.2 (range, 43–67) to 79.6 (range, 61–88) at last follow-up (p<0.05). In radiographic assessment, the patients showed 9.8 mm (range, 2.1 – 22.1) residual LLD at last follow-up. Conclusions. In the present study, patients with high hip dislocation who underwent primary THA showed improvement of gait pattern closer to that of normal hip joint. Although the patients showed improvement in gait analysis and clinical outcomes, but do not reach normal hip joint level and showed little residual antalgic gait pattern after THA

Aim. The effectiveness of mandatory joint aspiration prior to re-implantation in patients with a cement spacer already in place is unclear. The aim of this study was to evaluate the role of culturing articular fluid obtained by joint aspiration prior to re-implantation in patients who underwent a two stage septic revision. Method. A retrospective observational study was conducted, assessing51 patients that underwent a two stage septic hip or knee revision from 2010 to 2017. According to the results of intraoperative cultures, after the first stage revision each patient was treated with an antibiotic protocol for 6–8 weeks. Following two weeks without antibiotics, a culture of synovial fluid was obtained. Synovial fluid was obtained by direct joint aspiration in cases of knee spacers by and by joint aspiration guided by fluoroscopy in the theatre room in cases of hip spacers. Synovial fluid was transferred into a Vacutainer ACD. ®. flask. Samples were processed and analysed in the microbiology laboratory. Gram stains were performed and the sample was subsequently transferred into a BacALERT bottle (bioMérieux, France) and incubated in a BacALERT instrument for seven days. Results of these cultures were recorded and compared with cultures obtained during re-implantation surgery. Results. Of the 51 patients analysed, 9 were excluded because joint aspiration was not performed or the samples were not correctly processed. The remaining 42 patients (21 hip and 21 knee spacers) were included in the final analysis. In 40 cases, the culture of synovial fluid was negative while in the remaining two cases (hip spacers) no analysis was possible due to dry aspiration. In 5 of the patients, two or more intraoperative synovial fluid cultures taken during the re-implantation surgery were positive. Conclusions. Although in theory, synovial fluid culture may provide useful information regarding the infection status of the joint, in our study, we found no evidence to support mandatory joint aspiration prior to re-implantation in patients with a cement spacer in place

Reconstruction of massive acetabular bone defects in primary and revision THA is challenging for reconstructive joint surgeons. The use of porous metal augments is one of the options. The advantages of porous metal augments are easy to use, modularity and lack of resorption. We investigated the radiological results of porous metal augments used for massive acetabular bone defects in primary and revision THA. Forty-one hips in forty patients had porous metal augments between 2011 and 2016. Thirty of the procedures were revision arthroplasties and 11 were primary procedures (Crowe type III in 5 hips, Crowe type IV in 3, septic hip sequalae in 2 and RA in one). Four of the revisions were second-stage reimplantation after infection. The Paprosky classification for revision was 2B in 4 hips, 2C in one, 3A in 3 and 3B in 22. Regenerex augments were used in 39 hips and trabecular metal augments were used in 2. Thirty-six cups were cemented and 5 cups were uncemented. Mean follow-up was 37.6 months (range, 1–82). Radiographic findings of osteointegration between host bone and the porous metal augments were assessed. The presence or absence of radiolucent lines between cement or cup/host bone and augment/host bone interface was noted. Two revisions were performed due to infection, one month and 66 months after operation. The other implants were stable without any complications. Osteointegration between host bone and the porous metal augments were recognized in 36 hips. Radiolucent lines between cement/host bone interface, less than 1 mm in width, were visualized in 2 hips. Porous metal augments are convenient and our short-term results showed excellent radiological results for massive acetabular bone defects in primary and revision THA

Introduction: There is a paucity in the literature regarding the long term outcome of children with septic hips. Often, there is a delay in diagnosis which may lead to complications such as growth arrest, deformity and leg length discrepancy. We investigated the outcome of these patients and report the observed complications. Methods: We performed a retrospective review of all children who underwent arthrotomy and washout for septic arthritis of the hip over a ten year period. Patients were identified from hospital databases and the coding department. Medical records were reviewed and data including demographics, method of presentation, laboratory investigations and outcome were recorded. Results: We analysed the records of 70 patients who underwent formal arthrotomy and washout of their septic hip. Two patients had bilateral washouts (n = 72 hips). There were 36 (51%) female patients. 24 patients were under 1 year of age at presentation, with 11 of these in the neonatal period. Temperature data was available for 48 patients, with a mean of 38.2 degrees Celsius at presentation. The mean ESR was 55.8. 28 patients (40%) grew an organism on culture of the hip fluid. The most common organism was Staphylococcus Aureus (64% of positive cultures). 66% (n=16) of patients in the < 1 year old group developed complications relating to growth arrest and leg length discrepancy. Seven of these patients (43%) underwent further surgery to correct deformity at a later date. In contrast, only 4.3% of patients in the > 1 year old group developed complications. The mean delay to surgery in patients who developed complications was 6.3 days with a mean delay to surgery of 3.1 days in patients who did not develop complications (p = 0.03, student’s T-Test). Discussion: Paediatric Septic Arthritis remains a complex issue for both the patient and the surgeon. We have demonstrated that an increased delay in patients undergoing washout can lead to increased complications although this predominantly affects patients under 1 year of age. This can be explained by the lack of clinical signs in a < 1 year old child. Clinicians should have a high index of suspicion of septic arthritis in patients with features of sepsis with an unknown cause

In patients with primary hip replacement for previous infective arthritis the risk of recurrence of infection is of major concern. In addition, the safe time interval post infective arthritis for primary hip replacement is not known. Clinical & radiological results of consecutive series of 80 primary hip replacements performed for septic / tuberculous arthritis at Wrightington hospital from 1970 to 2008. Data was collected till latest follow up. Re-infection or revision for any reason was considered as primary end point for survivorship. Average age at primary hip replacement was 55.55 years (24 – 75). Mean follow up was 14.47 years (2–41). Twelve patients in septic hip group (n=42) needed revision out of which 6 (14%) were for infection. The survival rate for recent septic arthritis group (<10 years) was 60% at 7.5 years, whereas in old septic arthritis group (>10 years) it was 94.45% at 15.3 years, considering infection as end point. The survival rate was 60% for recent septic arthritis and 78.13% for old septic arthritis group over the same period of time considering revision for any reason as end point. In tuberculous group (n=38), the survival rate was 76.32% at 14.5 years of follow up, considering revision for any reason as end point. Significantly high re-infection rate in patients with recent septic arthritis was noted. No recurrence of infection in patients with old septic arthritis. No reactivation of tuberculosis in tuberculous arthritis group. This is the largest series with longest follow-up on primary total hip replacement for infective arthritis till date. Recent septic arthritis (<10Y) was a statistically high risk factor for recurrence of infection. Old septic arthritis is reasonably safe with 94.45% success rate at 15 years follow up. Old tuberculous arthritis is not a risk factor for hip replacement

Aims

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

Hip arthroscopy is particularly attractive in children as it confers advantages over arthrotomy or open surgery, such as shorter recovery time and earlier return to activity. Developments in surgical technique and arthroscopic instrumentation have enabled extension of arthroscopy of the hip to this age group. Potential challenges in paediatric and adolescent hip arthroscopy include variability in size, normal developmental change from childhood to adolescence, and conditions specific to children and adolescents and their various consequences. Treatable disorders include the sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’ disease and slipped capital femoral epiphysis, and the arthritic and septic hip. Intra-articular abnormalities are rarely isolated and are often associated with underlying morphological changes. This review presents the current concepts of hip arthroscopy in the paediatric and adolescent patient, covering clinical assessment and investigation, indications and results of the experience to date, as well as technical challenges and future directions

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

Current guidelines consider analyses of joint aspirates, including leucocyte cell count (LC) and polymorphonuclear percentage (PMN%) as a diagnostic mainstay of periprosthetic joint infection (PJI). It is unclear if these parameters are subject to a certain degree of variability over time. Therefore, the aim of this study was to evaluate the variation of LC and PMN% in patients with aseptic revision total knee arthroplasty (TKA).

Aim: To audit the impact of emergency hip ultrasound in the management of suspected hip septic arthritis. Methods and Results: Case series – Review of 13 consecutive patients who presented with acute hip pain, where clinical examination and inflammatory markers, highly suspicious of Septic arthritis. Emergency ultrasound was only available in 9 patients. Only 5 (38%) of these 13 patients had septic arthritis. Septic arthritis group. – Emergency ultrasound unavailable in 2 patents. They proceeded straight to arthrotomy yielding pus. – 3 had a preoperative ultrasound which confirmed the hip joint had an effusion. “Non Septic Arthritis of Hip” (8 patients). – In 2 patients emergency ultrasound unavailable. They underwent emergency arthrotomy with negative findings of pus. – 1 actually had septic arthritis of knee. – 6 patients did have emergency ultrasound which showed no effusion. Emergency arthrotomy was cancelled. – They proceeded to MRI of Hip. MRI revealed pathology close to but not involving the hip:. Pelvic osteomyelitis,. Psoas abscess,. Gluteal abscess secondary to small bowel fistula. Cellulitis of medial thigh. Femoral Epiphysis osteomyelitis. and inflammation of tendon secondary to line insertion. Inflammation of rectus femoris tendon (secondary to central line insertion). Conclusion: Use of ultrasound avoided unnecessary arthrotomy in 6 patients (48%). If ultrasound was available in all cases, then 8 (63%) patients would have avoided an unnecessary arthrotomy. Out of hours urgent hip ultrasound may be difficult to request. However our recent experience leads us to propose that if available ultrasound should be performed in all suspected case of hip septic arthritis prior to surgical drainage. Pathology in the vicinity of the hip can often masquerade convincingly as a septic hip joint

Introduction: In severe Legg-Calve-Perthes (LCPD) disease with subluxated femoral head, the acetabulum sometimes takes a bicompartmental appearance. This study analyzed acetabular pathoanatomy using a 3-D CT program. Materials and Methods: A 3-D CT software program that affords the section of 2-D image in any plane was used to analyze the acetabular pathoanatomy, with specific reference to the morphology of the inner surface of the acetabulum. Thirteen children with the bicompartmental acetabulae (12 LCPD and 1 AVN subsequent to septic hip arthritis) were evaluated. Results: The anterior half of the acetabulum was concentric. The contour of the acetabular margin in the posterior half of the acetabulum consisted of two different arcs – an arc of the iliac acetabulum (superior) and the other arc of the acetabular fossa of the ischium (medial). The junction of these two arcs was located at the triradiate cartilage, which was increased in mediolateral thickness at this point. The osteochondral articular margin of the ischium posterior to the non-articular acetabular fossa was thickened forming a ridge. The mediolateral thickness of the non-articular acetabular fossa was thinner than that of the normal contralateral side. The combination of these focal morphologic changes of the acetabular fossa rendered the bicompartmental appearance on plain AP radiograph of the pelvis. Discussion: The authors conclude that bicompartmentalization of the acetabulum apparently reflects the altered biomechanics of the hip joint due to the subluxated femoral head. The abnormal osteocartilaginous hypertrophy appears to be caused by synovial irritation and an eccentric molding effect of the subluxated femoral head

Bone loss, either due to a septic process or to surgical débridements, is frequently associated with bone infections. Bone loss may be present in septic non-unions, osteomyelitis or septic joint prosthesis. In each of these conditions the use of bone or bone substitutes may be indicated. However, the risk of septic recurrence makes the choice of the right implant in these patients particularly difficult. Clinical cases are presented to show the different choices available. Attention is focussed on: (1) when, in the presence of bone loss, a bone graft can be avoided and with which suitable procedures good results can be obtained; (2) when and how autologous bone grafts should be used; (3) when homologous bone grafts or bone substitutes are indicated; (4) how bone grafts should be protected against bacterial adesion and proliferation; and (5) the role of new technologies, such as bone growth factors. In this regard the clinical results are presented of the use of platelet-rich plasma (PRP) added to autologous or homologous bone after bone débridement in six patients treated with two-stage non-cemented revision of septic hip prosthesis and in two patients with septic non-union of the femur. At a minimum follow-up of 6 months (max. 1 year), we did not observe any infection recurrence, while bone remodelling and clinical outcome were favourable. The use of bone growth factors such as PRP possibly added to autologous or homologous bone appears to be a promising technique to achieve bone reconstruction in débrided bone infections. However, with the limited numbers of patients and the short-term follow-up conclusions cannot be drawn and the use of growth factors with this indication should be limited to selected cases: patients with wide bone loss and with no signs of active infections. No international guidelines are available concerning bone reconstruction in infections. Clinical experience shows that different surgical procedures are effective and the choice should take into considerations the type and site of bone defect, the host type and the pathogenesis of the bone loss. Growth factors may be a useful tool in these conditions and further studies are indicated

Aims

The aim of this study was to identify the incidence of positive cultures during the second stage of a two-stage revision arthroplasty and to analyse the association between positive cultures and an infection-free outcome.

Between September 2004 and December 2005 we carried out a prospective study of all cases of sepsis of the hip in childhood at a South African regional hospital with a large local population, and which also took referrals from nine rural hospitals. The clinical, radiological, ultrasound and bacteriological features were assessed. All the hips were drained by arthrotomy and the diagnosis was confirmed microbiologically and histologically. Hips with tuberculosis were excluded. The children were reviewed in a dedicated clinic at a mean follow-up of 8.1 months (3 to 18).

There were 40 hips with sepsis in 38 patients. Two patients were lost to follow-up. Nine (24%) had multi-focal sepsis. Overall, 13 hips (34%) had a full and uncomplicated clinical and radiological recovery and 25 (66%) had complications. All patients treated by arthrotomy and appropriate antibiotics within five days of the onset of symptoms had an uncomplicated recovery. Initial misdiagnosis was associated with a delay to arthrotomy. However, ‘deprivation’, consultation with a traditional healer, maternal educational attainment and distance to a primary health-care facility were not associated with delay to arthrotomy. The early correct diagnosis of this condition, common in the developing world, remains a significant factor in improving the clinical outcome.

A total of 31 patients, (20 women, 11 men; mean age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone resection-arthroplasty (RA) to a total hip replacement (THR) were compared with 93 patients, (60 women, 33 men; mean age 63.4 years old; 20 to 89), who had revision THR surgery for aseptic loosening in a retrospective matched case-control study. Age, gender and the extent of the pre-operative bone defect were similar in all patients. Mean follow-up was 9.3 years (5 to 18).

Pre-operative function and range of movement were better in the control group (p = 0.01 and 0.003, respectively) and pre-operative leg length discrepancy (LLD) was greater in the RA group (p < 0.001). The post-operative clinical outcome was similar in both groups except for mean post-operative LLD, which was greater in the study group (p = 0.003). There was a significant interaction effect for LLD in the study group (p < 0.001). A two-way analysis of variance showed that clinical outcome depended on patient age (patients older than 70 years old had worse pre-operative pain, p = 0.017) or bone defect (patients with a large acetabular bone defect had higher LLD, p = 0.006, worse post-operative function p = 0.009 and range of movement, p = 0.005), irrespective of the group.

Despite major acetabular and femoral bone defects requiring complex surgical reconstruction techniques, THR after RA shows a clinical outcome similar to those obtained in aseptic revision surgery for hips with similar sized bone defects.

Cite this article: Bone Joint J 2014;96-B:1478–84.

Ten patients, who were unsuitable for limb lengthening over an intramedullary nail, underwent lengthening with a submuscular locking plate. Their mean age at operation was 18.5 years (11 to 40). After fixing a locking plate submuscularly on the proximal segment, an external fixator was applied to lengthen the bone after corticotomy. Lengthening was at 1 mm/day and on reaching the target length, three or four screws were placed in the plate in the distal segment and the external fixator was removed. All patients achieved the pre-operative target length at a mean of 4.0 cm (3.2 to 5.5). The mean duration of external fixation was 61.6 days (45 to 113) and the mean external fixation index was 15.1 days/cm (13.2 to 20.5), which was less than one-third of the mean healing index (48 days/cm (41.3 to 55). There were only minor complications.

Lengthening with a submuscular locking plate can successfully permit early removal of the fixator with fewer complications and is a useful alternative in children or when nailing is difficult.

In this retrospective study we evaluated the proficiency of shelf autograft in the restoration of bone stock as part of primary total hip replacement (THR) for hip dysplasia, and in the results of revision arthroplasty after failure of the primary arthroplasty. Of 146 dysplastic hips treated by THR and a shelf graft, 43 were revised at an average of 156 months, 34 of which were suitable for this study (seven hips were excluded because of insufficient bone-stock data and two hips were excluded because allograft was used in the primary THR). The acetabular bone stock of the hips was assessed during revision surgery. The mean implant–bone contact was 58% (50% to 70%) at primary THR and 78% (40% to 100%) at the time of the revision, which was a significant improvement (p < 0.001). At primary THR all hips had had a segmental acetabular defect > 30%, whereas only five (15%) had significant segmental bone defects requiring structural support at the time of revision. In 15 hips (44%) no bone graft or metal augments were used during revision.

A total of 30 hips were eligible for the survival study. At a mean follow-up of 103 months (27 to 228), two aseptic and two septic failures had occurred. Kaplan-Meier survival analysis of the revision procedures demonstrated a ten-year survival rate of 93.3% (95% confidence interval (CI) 78 to 107) with clinical or radiological failure as the endpoint. The mean Oxford hip score was 38.7 (26 to 46) for non-revised cases at final follow-up.

Our results indicate that the use of shelf autografts during THR for dysplastic hips restores bone stock, contributing to the favourable survival of the revision arthroplasty should the primary procedure fail.

Cite this article: Bone Joint J 2013;95-B:777–81.

We compared the accuracy of the growth remaining method of assessing leg-length discrepancy (LLD) with the straight-line graph method, the multiplier method and their variants. We retrospectively reviewed the records of 44 patients treated by percutaneous epiphysiodesis for LLD. All were followed up until maturity. We used the modified Green–Anderson growth-remaining method (Method 1) to plan the timing of epiphysiodesis. Then we presumed that the other four methods described below were used pre-operatively for calculating the timing of epiphysiodesis. We then assumed that these four methods were used pre-operatively. Method 2 was the original Green–Anderson growth-remaining method; Method 3, Paley’s multiplier method using bone age; Method 4, Paley’s multiplier method using chronological age; and Method 5, Moseley’s straight-line graph method. We compared ‘Expected LLD at maturity with surgery’ with ‘Final LLD at maturity with surgery’ for each method. Statistical analysis revealed that ‘Expected LLD at maturity with surgery’ was significantly different from ‘Final LLD at maturity with surgery’. Method 2 was the most accurate. There was a significant correlation between ‘Expected LLD at maturity with surgery’ and ‘Final LLD at maturity with surgery’, the greatest correlation being with Method 2. Generally all the methods generated an overcorrected value. No method generates the precise ‘Expected LLD at maturity with surgery’. It is essential that an analysis of the pattern of growth is taken into account when predicting final LLD. As many additional data as possible are required.

Cite this article: Bone Joint J 2013;95-B:993–1000.

We retrospectively reviewed the records of 16 children treated for spondylodiscitis at our hospital between 2000 and 2007. The mean follow-up was 24 months (12 to 38). There was a mean delay in diagnosis in hospital of 25 days in the ten children aged less than 24 months. At presentation only five of the 16 children presented with localising signs and symptoms. Common presenting symptoms were a refusal to walk or sit in nine children, unexplained fever in six, irritability in five, and limping in four. Plain radiography showed changes in only seven children. The ESR was the most useful investigation when following the clinical course of the disease. Positive blood cultures were obtained in seven children with Staphylococcus aureus being isolated in five. Antibiotics were used in 14 children and spinal bracing in six. Children with spondylodiscitis often present with a confusing clinical picture leading to late diagnosis.

The early use of MRI in the investigation of children with an atypical picture may avoid unnecessary delay in starting treatment and possibly prevent long-term problems. All except one of our children had made a complete clinical recovery at final follow-up. However, all six children in the > 24-month age group showed radiological evidence of degenerative changes which might cause problems in the future.

In this study of 41 patients, we used proteomic, Western blot and immunohistochemical analyses to show that several reactive oxygen species scavenging enzymes are expressed differentially in patients with primary osteoarthritis and those with non-loosening and aseptic loosening after total hip replacement (THR). The patients were grouped as A (n = 16, primary THR), B (n = 10, fixed THR but requiring revision for polyethylene wear) and C (n = 15, requiring revision due to aseptic loosening) to verify the involvement of the identified targets in aseptic loosening. When compared with Groups A and B, Group C patients exhibited significant up-regulation of transthyretin and superoxide dismutase 3, but down-regulation of glutathione peroxidase 2 in their hip synovial fluids. Also, higher levels of superoxide dismutase 2 and peroxiredoxin 2, but not superoxide dismutase 1, catalase and glutathione perioxidase 1, were consistently detected in the hip capsules of Group C patients.

We propose that dysregulated reactive oxygen species-related enzymes may play an important role in the pathogenesis and progression of aseptic loosening after THR.

We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children.

Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.