Background. Well-fixed cementless stems are sometimes needed to be extracted in patients with complications including periprosthetic infection, stem-neck breakage or trunnionosis. The purpose of this study was to report the clinical outcome in patients undergoing re-implantation surgery following removal of a well-fixed porous-coated cementless stem by the femoral longitudinal split (FLS) procedure(Fig.1, Fig.2). Methods. We conducted a retrospective study and radiographic review of 16 patients who had undergone re-implantation following the FLS procedure to remove a well-fixed stem due to periprosthetic infection, stem-neck breakage or trunnionosis. The study group consisted of 2 men and 14women with an average age of 68.4 years. Mean follow-up was 33.1± 25.0 months. Operation time, intraoperative bleeding, complications, causes of re-operation and clinical score were evaluated and the Kaplan-Meier method was used to evaluate the longevity of the stem. Results. The average operation time was 272±63 minutes and intraoperative bleeding was 420±170 ml. Although postoperative dislocation occurred in 5 hips and sinking of the stem was found in 3 hips after surgery, no progression of the stem sinking was observed and the clinical JOA and JHEQ scores were both improved after re-implantation surgery. Re-implantation surgery with Zweymüller-type stems, which are shorter than those removed, revealed evidence of osseointegration of the stem without femoral fracture. Kaplan-Meier survival analysis of stem revision for any reason as the end point revealed 70.3% survival at 9 years (Fig.3). Conclusion. The FLS procedure is expected to confer successful clinical results without loosening of the stem, following safe extraction of well-fixed porous-coated cementless stems without fracture and will allow re-implantation with shorter cementless stems than those removed. For any figures or tables, please contact the authors directly

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

There remains to be substantial debate on the best treatment of the infected shoulder arthroplasty. Infection after shoulder arthroplasty is an uncommon but devastating complication with a reported incidence from 0 to 4%. The most common organism responsible for infection following rotator cuff surgery, instability surgery, ORIF proximal humerus fractures, and shoulder arthroplasty is Prop. Acnes. A thorough history is important because many patients have a history of difficulty with wound healing or drainage. Prop. Acnes typically does not start to grow until day 5, therefore it is critical to keep cultures a minimum of 10 to 14 days. Diagnosis can be difficult, particularly among patients undergoing revision surgery. The majority of patients with a low grade infection do not have overt signs of infection such as erythema or sinus tracts. Preoperative lab values as well as intraoperative pathology have been shown to be unreliable in predicting who will have positive cultures at the time of revision surgery. There are a number of options for treating a patient with a post-operative infection. Critical variables include the timing of infection, status of the host, the specific organism, status of implant fixation, and the status of the rotator cuff and deltoid. One of the most frequently employed options for treating the infected shoulder arthroplasty is two-stage re-implantation. However, the rate of complications with this technique as well as residual infection remains high

Aims. Metal-on-metal total hip replacements (MoM THRs) are frequently revised. However, there is a paucity of data on clinical outcomes following revision surgery in this cohort. We report on outcomes from the largest consecutive series of revisions from MoM THRs and consider pre-revision factors which were prognostic for functional outcome. Materials and Methods. A single-centre consecutive series of revisions from MoM THRs performed during 2006–2015 was identified through a prospectively maintained, purpose-built joint registry. The cohort was subsequently divided by the presence or absence of symptoms prior to revision. The primary outcome was functional outcome (Oxford Hip Score (OHS)). Secondary outcomes were complication data, pre- and post-revision serum metal ions and modified Oxford classification of pre-revision magnetic resonance imaging (MRI). In addition, the study data along with demographic data was interrogated for prognostic factors informing on post-revision functional outcome. Results. 180 revisions in 163 patients were identified at a median follow-up of 5.48 (2–11.7) years. There were 152 (84.4%) in the symptomatic subgroup and 28 (15.6%) in the asymptomatic group. Overall median OHS improved from 29 to 37 with revision (P<0.001). Symptomatic patients experienced greater functional benefit (DOHS 6.5 vs. 1.4, p=0.012) compared to asymptomatic patients, though they continued to report inferior outcomes (OHS 36.5 vs 43, p=0.004). The functional outcome of asymptomatic patients was unaffected by revision surgery (pre-revision OHS 41, post-revision OHS 43, p=0.4). Linear regression analysis confirmed use of a cobalt-chrome (CoCr)-containing bearing surface (MoM or metal-on- polyethylene) at revision and increasing BMI were predictive of poor functional outcome (R. 2. 0.032, p=0.0224 and R. 2. 0.039, p=0.015 respectively). Pre- and post-revision serum metal ions and pre-revision MRI findings were not predictive of outcome. The overall complication rate was 36% (n=65) with a re-revision rate of 6.7%. The most common complication was ongoing adverse reaction to metal debris (ARMD, defined as positive post-revision MRI) in 21.1%. The incidence of ongoing ARMD was not significantly different between those with CoCr reimplanted and those without (p=0.12). Conclusions. To our knowledge, our study represents the largest single-centre consecutive series of revision THRs from MoM bearings in the literature. Symptomatic patients experience the greatest functional benefit from revision surgery but do not regain the same level of function as patients who were asymptomatic prior to revision. The re-implantation of CoCr as a primary bearing surface and increasing BMI was associated with poorer functional outcome

Aim. Diagnosis of periprosthetic joint infection (PJI) is challenging given the limitations of available diagnostic tests. Recently, several studies have shown a role of the long pentraxin PTX3 as a biomarker in inflammatory diseases and infections. This single-center prospective diagnostic study evaluated the diagnostic ability of synovial fluid and serum PTX3 for the infection of total hip arthroplasty (THA) and total knee arthroplasty (TKA). Method. Consecutive patients undergoing revision surgery for painful THA or TKA were enrolled. Patients with antibiotic therapy suspended for less than 2 weeks prior to surgery and patients eligible for metal-on-metal implant revision or spacer removal and prosthesis re-implantation were excluded. Quantitative assessment of synovial fluid and serum PTX3 was performed with ELISA method. Musculoskeletal Infection Society (MSIS) criteria were used as reference standard for diagnosis of PJI. Continuous data values were compared for statistical significance with univariate unpaired, 2-tailed Student's t-tests. Receiver operating characteristic (ROC) curve analyses was performed to assess the ability of serum and synovial fluid PTX3 concentration to determine the presence of PJI. Youden's J statistic was used to determine optimum threshold values for the diagnosis of infection. Sensitivity (Se), specificity (Sp), positive (PPV) and negative (NPV) predictive values, positive (LR+) and negative (LR-) likelihood ratio, area under the ROC curve (AUC) were calculated. Results. One-hundred fifteen patients (M:F=49:66) with a mean age of 62 years (40–79) underwent revision of THA (n=99) or TKA (n=16). According with MSIS criteria, 18 cases were categorized as septic and 97 as aseptic revisions. The average synovial fluid concentration of PTX3 was significantly higher in patients with PJI compared to patients undergoing aseptic revision (24,3 ng/dL vs 3,64 ng/dL; P=0.002). There was no significant difference in terms of serum concentration of PTX3 between the two groups. Synovial fluid PTX3 demonstrated an AUC of 0.96 (95%IC 0.89–0.98) with Se 94%, Sp 90%, PPV 67%, NPV 100%, LR+ 9.4 and LR- 0.06 for a threshold value of 4.5 ng/dL. Serum PTX3 demonstrated an AUC of 0.70 (95%IC 0.51–0.87) with Se 72%, Sp 67%, PPV 30%, NPV 93%, LR+ 2.2 and LR- 0.42 for a threshold value of 4.5 ng/dL. Conclusions. In patients undergoing revision surgery for painful THA or TKA, synovial PTX3 demonstrated a strong diagnostic ability for PJI. Synovial PTX3 could represent a more useful biomarker for detection of PJI compared with serum PTX3

There continues to be significant debate on the optimum treatment of the infected shoulder arthroplasty. Infection after shoulder arthroplasty is an infrequent but devastating complication with a reported incidence from 0 to 4%. The most common organism responsible for infection following rotator cuff surgery, instability surgery, ORIF proximal humerus fractures, and shoulder arthroplasty is P. acnes. A thorough history is important because many patients have a history of difficulty with wound healing or drainage. P. acnes typically does not start to grow until day 5, therefore it is critical to keep cultures a minimum of 10 to 14 days. Diagnosis can be challenging, particularly among patients undergoing revision surgery. The majority of patients with a low grade infection do not have overt signs of infection such as erythema or sinus tracts. Pre-operative lab values as well as intra-operative pathology have been shown to be unreliable in predicting who will have positive cultures at the time of revision surgery. There are a number of options for treating a patient with a post-operative infection. Essential variables include the timing of infection, status of the host, the specific organism, status of implant fixation, and the status of the rotator cuff and deltoid. One of the most frequently employed options for treating the infected shoulder arthroplasty is two stage re-implantation. However, the rate of complications with this technique as well as residual infection remains high

Infection after shoulder arthroplasty is an uncommon but devastating complication with a reported incidence from 0% to 4%. Prop. Acnes is the most common organism responsible for infection following rotator cuff surgery, instability surgery, ORIF proximal humerus fractures, and shoulder arthroplasty. A detailed history is critical because many patients have a history of difficulty with wound healing or drainage. Prop. Acnes typically does not start to grow until Day 5, therefore it is critical to keep cultures a minimum of 10 to 14 days. Diagnosis can be difficult, particularly among patients undergoing revision surgery. The majority of patients with a low grade infection do not have overt signs of infection such as erythema or sinus tracts. Pre-operative lab values as well as intra-operative pathology have been shown to be unreliable in predicting who will have positive cultures at the time of revision surgery. There are a number of options for treating a patient with a post-operative infection. Important variables include the timing of infection, status of the host, the specific organism, status of implant fixation, and the status of the rotator cuff and deltoid. One of the most frequently employed options for treating the infected shoulder arthroplasty is two-stage re-implantation. However, the rate of complications with this technique as well as residual infection remains high

The following papers will be discussed during this session: 1) Staph Screening and Treatment Prior to Elective TJA; 2) Unfulfilled Expectations Following TJA Procedures; 3) Thigh Pain in Short Stem Cementless Components in THR; 4) Is the Direct Anterior Approach a Risk Factor for Early Failure?; 5) THA Infection - Results of a 2nd 2-Stage Re-implantation - Clinical Trial of Articulating and Static Spacers; 6) THA Revision - Modular vs. Non Modular Fluted Tapered Stems-Total Femoral Replacement for Femoral Bone Loss - Cage + TM Augment vs. Cup Cage for Acetabular Bone Loss; 7) Do Injections Increase the Risk of Infection Prior to TKA?; 8) Long-Acting Opioid Use Predicts Perioperative Complication in TJA; 9) UKA vs. HTO in Patients Under 55 at 5–7 years; 10) Stemming Tibial Component in TKA Patients with a BMI > 30; 11) The Effect of Bariatric Surgery Prior to Total Knee Arthroplasty; 12) Oral Antibiotics and Reinfection Following Two-Stage Exchange; 13) Two-Stage Debridement with Prosthetic Retention for Acute TKA Infections; 14) Patient-Reported Outcomes Predict Meaningful Improvement after TKA; 15) Contemporary Rotating Hinge TKA; 16) Liposomal Bupivacaine in TKA; and 17) Noise Generation in Modern TKA: Incidence and Significance

Background. Periprosthetic joint infection (PJI) is a devastating complication and interest exists in finding lower cost alternatives to current management strategies. Current strategies include a two-stage revision with placement of an antibiotic spacer and delayed placement of a new arthroplasty implant. This study aimed to show that biofilm residue can be reliably eradicated on infected implants, safely allowing re-implantation in a spacer. Methods. Strains of Staphylococcus aureus MRSA252 or Staphylococcus epidermidis RP62A were grown on cobalt-chrome discs. For each strain, discs were divided into 5 groups (5 discs each) and exposed to several sterilization and biofilm eradication treatments: (1) autoclave, (2) autoclave + sonication; (3) autoclave + saline scrub; (4) autoclave + 4% chlorhexidine (CHC) scrub; and (5) autoclave + sonication + CHC scrub. Sterilization and biofilm eradication were quantified with crystal violet assays and scanning electron microscopy (SEM). Results. Relative to non-treated controls, autoclaving alone reduced biofilm load by 33.9% and 54.7% for MRSA252 and RP62A strains, respectively. On average, the most effective sterilization and biofilm removal treatment was the combined treatment of autoclaving, sonication and CHC-scrub for MRSA252 (100%) and RP62A (99.8%). High resolution SEM revealed no cells or biofilm for this combined treatment. Conclusions. Using two commonly encountered bacterial strains in PJI, infected cobalt-chrome implants were sterilized and eradicated of residual biofilm with a combination of autoclaving, sonication and CHC scrubbing. This protocol is time efficient, can be done in the OR and provides a basis for reuse of infected implants as articulating spacers in PJI

Aim. Diagnosis of periprosthetic joint infection (PJI) is still challenging due to limitations of available diagnostic tests. Many efforts are ongoing to find out novel methods for PJI diagnosis. Recently, several studies have shown a role of the long pentraxin PTX3 as a biomarker in inflammatory diseases and infections. This pilot diagnostic study evaluated the diagnostic ability of synovial fluid and serum PTX3 for the infection of total hip arthroplasty (THA) and total knee arthroplasty (TKA). Method. Consecutive patients undergoing revision surgery for painful THA or TKA were enrolled. Patients with antibiotic therapy suspended for less than 2 weeks prior to surgery and patients eligible for spacer removal and prosthesis re-implantation were excluded. Quantitative assessment of synovial fluid and serum PTX3 was performed with ELISA method. Musculoskeletal Infection Society (MSIS) criteria were used as reference standard for diagnosis of PJI. Continuous data values were compared for statistical significance with univariate unpaired, 2-tailed Student's t-tests. Receiver operating characteristic (ROC) curve analyses was performed to assess the ability of serum and synovial fluid PTX3 concentration to determine the presence of PJI. Youden's J statistic was used to determine optimum threshold values for the diagnosis of infection. Sensitivity (Se), specificity (Sp), positive (PPV) and negative (NPV) predictive values, positive (LR+) and negative (LR-) likelihood ratio, area under the ROC curve (AUC) were calculated. Results. Sixty-two patients (M:F=28:34) with a mean age of 64 years (40–78) underwent revision of THA (n=52) or TKA (n=10). According with MSIS criteria, 10 cases were categorized as septic and 52 as aseptic revisions. The average synovial fluid concentration of PTX3 was significantly higher in patients with PJI compared to patients undergoing aseptic revision (23,56 ng/mL vs 3,71 ng/mL; P=0.0074). There was no significant difference in terms of serum concentration of PTX3 between the two groups. Synovial fluid PTX3 demonstrated an AUC of 0.93 (95%IC 0.86–0.97) with Se 100%, Sp 85%, PPV 55%, NPV 100%, LR+ 6.6 and LR- <0.01 for a threshold value of 3 ng/mL. Serum PTX3 demonstrated an AUC of 0.59 (95%IC 0.38–0.8) with Se 78%, Sp 50%, PPV 25%, NPV 90%, LR+ 1.56 and LR- 0.44 for a threshold value of 3 ng/mL. Conclusions. Synovial PTX3 demonstrated a strong diagnostic ability for PJI. PTX3 could represent a useful biomarker for detection of PJI in patients undergoing revision surgery for painful THA or TKA. Larger diagnostic studies are required to confirm these preliminary data

For most complex primary total knee replacement there is associated soft tissue and bone loss. A constrained condylar implant can be useful in improving the stability of the knee after revision. Augmentation is commonly used to deal with bone loss on the femoral and tibial side of the joint. Stems are known to reduce the load at the interface of the femoral and tibial component and transfer the load into the medullary canals. There are problems with using stems in the complex primary knee setting however, which include: (1) increased cost, (2) difficulty with removal should further revision be necessary, (3) violation of the intramedullary canals if infection occurs, (4) increased operating time. For these reasons a CCK implant was developed without stems in 1998. The use of this device must be very selective and it is primarily used for severe valgus deformity in elderly patients. In a revision setting where there is good preservation of femoral and/or tibial bone but the need for increased constraint is present (e.g. unicompartmental, cruciate retaining knee) a CCK without stems can be used with good results. We retrospectively reviewed 36 primary constrained condylar knee implants without stem extensions from 1998 to 2000 in 31 patients with knees in 15 degrees valgus or greater. All patients were followed up for a minimum 10 years (range, 10 to 12 years). One patient had aseptic loosening and needed to be revised with stemmed components at 9 years post surgery. Wear was found in two patients. One patient, with severe rheumatoid arthritis, had infection and required a two-stage re-implantation procedure. Patients who are very active or heavy body weight where stresses may be excessive at the implant bone interface should have stems utilised

At first-stage revision surgery for infection of total knee arthroplasties, antibiotic-impregnated cement spacers are frequently implanted. Two types of cement spacers are commonly used, “static” and “articulating” cement spacers. Advocates of cement spacers state that they deliver high doses of antibiotics locally, increase patient comfort, allow mobility and provide joint stability. They also minimize contracture of collateral ligaments, thereby facilitating re-implantation of a definitive prosthesis at a later stage. The use of these cement spacers, however, are not without significant complications, including patella tendon injuries. We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision. The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12–20. Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries

Infection after shoulder surgery is an infrequent but devastating complication with a reported incidence from 0 to 4%. A careful history is critical because many patients have a history of a “stitch abscess” or “superficial wound infection”. Prop. Acnes is the most common organism responsible for infection following rotator cuff surgery, instability surgery, ORIF proximal humerus fractures, and shoulder arthroplasty. This organism typically does not start to grow until Day 5, therefore it is critical to keep cultures a minimum of 10 to 14 days. The diagnosis can be challenging, principally among patients undergoing revision surgery. The majority of patients with a low grade infection do not have blatant signs of infection such as erythema or sinus tracts. Pre-operative lab values as well as intra-operative pathology have been shown to be unreliable in predicting who will have positive cultures at the time of revision surgery. There is an assortment of options for treating a patient with a post-operative infection. Important variables include the timing of infection, status of the host, the specific organism, status of implant fixation, and the status of the rotator cuff and deltoid. One of the most frequently employed options for treating the infected shoulder arthroplasty is two stage re-implantation. However, the rate of complications with this technique as well as residual infection remains high

This study aimed to determine the optimal formulation of antibiotic-loaded bone cement (ALBC) for periprosthetic joint infection (PJI) using both in vitro and in vivo models incorporating various combinations of gram-positive and gram-negative antibiotics. The in vitro antibiotic release characteristics and antibacterial capacities of ALBCs loaded with either 4 g of vancomycin or teicoplanin and 4 g of ceftazidime, imipenem, or aztreonam were measured against methicillin-susceptible S. aureus, methicillin-resistant S. aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa and Escherichia coli. ALBC spacers with superior in vitro antibacterial capacity were then implanted into ten patients (five females and five males between 29 and 75 years of age) diagnosed with chronic hip/knee PJIs and antibacterial activities within joint fluid were measured. The average duration of ALBC spacer implantation was 80 days (range, 36–155 days). Antibiotic concentrations and antibacterial activities of joint fluid at the site of infection were measured during the initial period as well as several months following spacer implantation. Cement samples loaded with vancomycin/ceftazidime or teicoplanin/ceftazidime exhibited equal or longer antibacterial duration against test bacteria as compared with other ALBCs. Joint fluid samples exhibited antibacterial activity against the test microorganisms including ATCC strains and clinically isolated strains. There were no adverse systemic effects, infection at second stage re-implantation, or recurrent infection at final follow-up. Vancomycin/ceftazidime ALBC provided broad antibacterial capacity both in vitro and in vivo and was shown to be an effective and safe therapeutic measure in the treatment of hip/knee PJIs. We thank H.Y. Hsu for performing bioassay

For most revision total knee replacement there is associated soft tissue and bone loss. A constrained condylar implant can be useful in improving the stability of the knee after revision. Augmentation is commonly used to deal with bone loss on the femoral and tibial side of the joint. Stems are known to reduce the load at the interface of the femoral and tibial component and transfer the load into the medullary canals. There are problems with using stems in the revision setting however, which include: (1) increased cost, (2) difficulty with removal should further revision be necessary, (3) violation of the intramedullary canals if infection occurs, (4) increased operating time. For these reasons a CCK implant was developed without stems in 1998. The use of this device must be very selective and it is primarily used for severe valgus deformity in elderly patients. In a revision setting where there is good preservation of femoral and/or tibial bone but the need for increased constraint is present (e.g. unicompartmental, cruciate retaining knee) a CCK without stems can be used with good results. We retrospectively reviewed 36 primary constrained condylar knee implants without stem extensions from 1998 to 2000 in 31 patients with knees in 15 degrees valgus or greater. All patients were followed up for a minimum 10 years (range, 10 to 12 years). One patient had aseptic loosening and needed to be revised with stemmed components at 9 years post-surgery. Wear was found in two patients. One patient, with severe rheumatoid arthritis, had infection and required a two-stage re-implantation procedure. Patients who are very active or heavy body weight where stresses may be excessive at the implant bone interface should have stems utilised

To report our experience with the use of local antibiotic co-delivery with a synthetic bone graft substitute during a second stage re-implantation of an infected proximal humeral replacement. A 72 year old man was admitted to our department with a pathological fracture through an osteolytic lesion in the left proximal humerus, due to IgG Myelomatosis. He was initially treated with a cemented proximal humerus replacement hemiarthroplasty. Peri-prosthetic joint infection (PJI) with significant joint distention was evident three weeks post operatively. Revision surgery confirmed presence of a large collection of pus and revealed disruption of the soft tissue reattachment tube, as well as complete retraction of rotator cuff and residual capsule. All modular components were removed and an antibiotic-laden cement spacer (1.8g of Clindamycin and Gentamycin, respectively) was implanted onto the well-fixed cemented humeral stem. Initial treatment with i.v. Amoxicillin/Clavulanic acid was changed to Rifampicin and Fusidic Acid during a further 8 weeks after cultures revealed growth of S. epidermidis. During second stage revision, a hybrid inverse prosthesis with silver coating was implanted, with a total of 20 ml Cerament ™G (injected into the glenoid cavity prior to insertion of the base plate and around the humeral implant-bone interface) and again stabilized with a Trevira tube. Unfortunately, this prosthesis remained unstable, ultimately requiring re-revision to a completely new constrained reverse prosthesis with a custom glenoid shell and silver-coated proximal humeral component. 18 months postoperatively, the patient's shoulder remains pain free and stable, without signs of persistent or reinfection since the initial second stage revision. The function however, unfortunately remains poor. This case report illustrates the application of an antibiotic-eluting bone graft substitute in a specific clinical situation, where co-delivery of an antibiotic together with a bone remodeling agent may be beneficial to simultaneously address PJI as well as poor residual bone quality

Several risk factors can and should be addressed during first stage or spacer implantation surgery in order to minimize complications. Technical aspects as well as practical tips and pearls to overcome common nuisances such as spacer instability or femoral and acetabular bone loss will be discussed and shown with pictures. Total joint arthroplasty (TJA) is one of the most successful procedures in orthopaedics and excellent results are expected in virtually all cases. Periprosthetic joint infection (PJI) though unusual, is one of the most frequent and challenging complications after TJA. It is the third most common cause of revision in total hip replacement, responsible for up to 15% of all cases. In the past few years several improvements have been made in the management of an infected total hip prosthesis. Nevertheless it remains a challenging problem for the orthopaedic surgeon. Although numerous studies report favourable outcomes after one-stage revision surgery, two-stage has traditionally been considered as the gold standard for management of chronic infection. Two-stage exchange consists of debridement, resection of infected implants and usually temporary placement of an antibiotic-impregnated cement spacer before reimplantation of a new prosthesis. Spacers can be classified as static or articulating. The goals of using an articulating antibiotic loaded cement spacer are two-fold: to enhance the clearance of infection by local antibiotic therapy and dead-space management while maintaining joint function during treatment thus improving the functional outcome at reimplantation. Still, hip spacer implantation is not innocuous and there are several possible complications. Going forward, one must consider not just eradicating infection but also the importance of restoring function. In this regard using a mobile spacer adds an element of physiologic motion that both increases patient comfort between stages and facilitates re-implantation surgery. Conversely, mechanical complications are one of the major consequences of this preference. Be that as it may there are ways to minimize these problems. It is the surgeon responsibility to optimize mechanical circumstances as much as possible. I would like to thank Dr. Ricardo Sousa for his help with this work

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

Over a four year period of time, 142 consecutive hip revisions were performed with the use of an extended proximal femoral osteotomy. Twenty patients had insufficient follow-up or were followed elsewhere and were excluded from the review. The remaining 122 revisions included 83 women and 39 men. Average age at time of revision was 63.8 (26–84) years. Indications for revision were aseptic loosening (114), component failure (4), recurrent dislocation (2), femoral fracture (1) and second stage re-implantation for infection (1). The extended proximal femoral osteotomy gave easy access to the distal bone-cement or bone prosthesis interface in all cases. It allowed neutral reaming of the femoral canal and implantation of the revision component in proper alignment. Varus remodeling of the proximal femur secondary to loosening was handled with relative ease implementing the osteotomy. Average time from the beginning of the osteotomy procedure to the complete removal of prosthesis and cement was 35 minutes. There were no non-unions of the osteotomised fragments at an average post-operative follow-up of 2.6 years with no cases of proximal migration of the greater trochanteric fragment greater than 2 mm, there was evidence of radiographic union of the osteotomy site in all cases by 3 months. Stem fixation with bone ingrowth was noted in 112 (92%) of 122 hips, stable fibrous fixation was seen in 9 (7%) and 1 stem was unstable and was subsequently revised. However, there was an incidence of 7% perforation rate of the femoral canal distal to the osteotomy site during cement removal. This was most prevalent where there was greater than 2 cm of cement plug present which was well bonded. When OSCAR was used instead of hand tools or power reamers, there were no perforations in 51 cases. There has been no failure of fixation with fully porous coated stems inserted in the canals where OSCAR had removed cement. Also, the use of OSCAR has allowed us to shorten the osteotomy, thus allowing a longer, intact isthmus to remain so that shorter stems can be used. We highly recommend the use of OSCAR in conjunction with the extended osteotomy for removal of well-fixed distal cement beyond the extended osteotomy site

Background. Septic knee arthritis is one of the most serious complications after total knee arthroplasty (TKA), and the effectiveness of its treatment affects the patient's quality of life. In our super-aging society, the frequency of TKA in the elderly, often combined with various comorbidities, is increasing. Careful management should be considerd during the management of septic arthritis after TKA in these patients. Purpose. To analyze the clinical features and outcomes of septic arthritis after TKA in our institution. Materials and Methods. Between April 1999 and March 2014, 534 TKAs (osteoarthritis [OA]; 381, rheumatoid arthritis [RA]; 154) were performed. Of these patients, 8 with post-operative infected TKA were retrospectively surveyed. Results. The TKA-associated infection rates were 0.83% (0.35%, OA; 1.7%, RA) during the study period. Five male and 3 female patients were included, with a mean age of 68 years (range, 39–88 years) and primary diagnoses of OA (5) and RA (3). Malignant rheumatoid arthritis (MRA) was present in 1 patient. The infection was affected by a comorbidity in 2 (diabetes mellitus and mixed connective tissue disease). Microorganisms were detectable in 7 patients (methicillin-resistant Staphylococcus aureus [MRSA], 1; methicillin-sensitive Staphylococcus aureus, 2; Streptococcus pyogens, 1; Streptococcus oralis, 1; Escherichia coli, 1; Staphylococcus epidermidis, 1; and unknown, 1) (Fig. 1). The use of the Segawa/Leone classification resulted in 5 patients with type III (acute hematogenous) and 3 with type IV (late) infections. Four patients with type III (80%) infection underwent open debridement, continuous irrigation, and successful implant retention (Fig. 2). The MRA patient had type III infection and an MRSA infection that was treated with two-stage revision, but the infection recurred. We could not perform a re-implantation, and resection arthroplasty was needed. Arthroscopic irrigation in 1 patient with type III infection ended in failure, and open debridement was required. We attempted to retain the implant in 1 patient with type IV infection, but implant removal was required. Three patients with type IV infection underwent two-stage revision successfully. Discussion. The post-TKA infection rate was 0.83% in our institution. Of the implants, 50% (type III, 80%; type IV, 0%) were successfully retained. Early open debridement and irrigation are important for implant retention in patients with infected TKAs, while arthroscopic debridement does not appear to be effective for infected TKA. Implant retention was difficult in the presence of resistant microorganisms. Two-stage revision was required in patients with type IV infection, with a success rate of 75%