Introduction. Retention and removal of children's orthopaedic metalwork is a contentious issue that has implications for current resource allocation, health economics, complication risks and can impact on future treatments. Understanding how to guide families make informed choices requires an overview of all the relevant evidence to date, and knowledge of where the evidence is lacking. Our aim was to systematically review the literature and provide a meta-analysis where possible, recommending either retention or removal. Materials and Methods. A search of the literature yielded 2420 articles, of which 22 papers were selected for the study analysis. Inclusion criteria: Any paper (evidence level I-IV) assessing the risks or benefits of retaining or removing orthopaedic metalwork in children. Exclusion criteria: Spinal implants; implant number < 40; < 75% recorded follow up; papers including implants in their analysis that always require removal; patients aged >18 years. Results. In total, 4988 patients (6412 implants) were included across all 22 studies. There was a significant amount of heterogenicity between studies. Overall the short term risks of metalwork retention and removal are low, with a few exceptions. In forearm plating re-fracture rates following removal were lower than those seen in studies looking at retained metalwork, provided removal occurred later than 12 months from the initial operation. Forearm re-fracture rates after removal of flexible nails significantly increased if removal was performed before 6 months. Major complications following routine metalwork removal from the proximal femur are relatively rare, with re-fracture rates of 1–5%. The majority of these re-fractures are seen in neuromuscular patients or in patients where removal occurs earlier than 6 months. Routine metalwork removal following SUFE had a complication rate of 30–60%. Conclusions. We found that there are certain subgroups of children that benefit from retention of metalwork and some that benefit from removal. There are several subgroups that we have identified which do not yet have sufficient long term evidence to make a balanced recommendation. We advise that families are made aware of what is known and what is unknown in order to allow for shared decision making

Aims. Fracture-Related Infection (FRI) is a severe complication caused by microbial infection of bone. It is imperative to gain more insight into the potentials and limitations of Debridement, Antibiotics and Implant Retention (DAIR) to improve future FRI treatment. The aims of this study were to: 1) determine how time to surgery affects the success rate of DAIR procedures of the lower leg performed within 12 weeks after the initial fracture fixation operation and 2) evaluate whether appropriate systemic antimicrobial therapy affects the success rate of a DAIR procedure. Methods. This multinational retrospective cohort study included patients of at least 18-years of age who developed an FRI of the lower leg within 12 weeks after the initial fracture fixation operation, between January 1st 2015 to July 1st 2020. DAIR success was defined by the absence of recurrence of infection, preservation of the affected limb and retention of implants during the initial treatment. The antimicrobial regimen was considered appropriate if the pathogen(s) was susceptible to the given treatment at the correct dose as per guideline. Logistic regression modelling was used to assess factors that could contribute to the DAIR success rate. Results. A total of 120 patients were included, of whom 70 DAIR patients and 50 non-DAIR patients. Within a median follow-up of 35.5 months, 21.4% of DAIR patients developed a recurrent FRI compared to 12.0% of non-DAIR patients. The DAIR procedure was successful in 45 patients (64.3%). According to the Willenegger and Roth classification, DAIR success was achieved in 66.7% (n=16/24) of patients with an early infection (<2 weeks), 64.4% (n=29/45) of patients with a delayed infection (2–10 weeks) and 0.0% (0/1) of patients with a late infection (>10 weeks). Univariate analysis showed that the duration of infection was not associated with DAIR success in this cohort (p=0.136; OR: 0.977; 95%CI: [0.947–1.007]). However, an appropriate antimicrobial regimen was associated with success of DAIR (p=0.029; OR: 3.231; 95%CI: [1.138–9.506]). Conclusions. Although the results should be interpreted with caution, an increased duration of infection was not associated with a decreased success rate of a DAIR procedure in patients with FRI of the lower leg. The results of this study highlight the multifactorial contribution to the success of a DAIR procedure and emphasize the importance of adequate antimicrobial treatment. Therefore, time to surgery should not be the only key-factor when considering a DAIR procedure to treat FRI

Aim. Debridement, Antibiotics, Irrigation, and implant Retention (DAIR) is a surgical treatment protocol suitable for some patients with fracture related infection (FRI). Clinically relevant pre-clinical models of DAIR are scarce and none have been developed in large animals. Therefore, this project aimed to develop a large animal model for FRI including a DAIR approach and compare outcomes after 2 or 5 weeks of infection. Method. Swiss Alpine sheep (n=8), (2–6 years, 50–80 kg) were included in this study. This study was approved by cantonal Ethical authorities in Chur, Switzerland. A 2 mm osteotomy was created in the tibia and fixed with a 10-hole 5.5 mm steel plate. Subsequently, 2.5 mL of saline solution containing 10. 6. CFU/mL of Staphylococcus aureus MSSA (ATCC 25923) was added over the plate. Sheep were observed for 2 (n=3) or 5 weeks (n=5) until revision surgery, during which visibly infected or necrotic tissues were removed, and the wound flushed with saline. All samples were collected for bacterial quantification. After revision surgery, the sheep were treated systemically for 2 weeks with flucloxacillin and for 4 weeks with rifampicin and cotrimoxazole. After 2 further weeks off antibiotics, the animals were euthanized. Bacteriological culture was performed at the end of the study. Bone cores were isolated from the osteotomy site and processed for Giemsa & Eosin and Brown and Brenn staining. A radiographical examination was performed every second week. Results. Bacteriological evaluation of the retrieved samples during revision surgery showed no significant difference between the 2 vs 5 weeks infection periods in term of total CFU counts. At the end of the study, radiographical examination showed callus formation over the osteotomy site in both groups, although the osteotomy was not completely healed in either group. At euthanasia, the 2 weeks infection group showed a higher soft tissue burden compared to the 5 weeks group, whereby the infection in the 5 weeks group was primarily located in the bone and bone marrow. Conclusions. The large animal model of FRI and DAIR was successfully established. Bacteriological outcomes highlight that the increasing duration of the infection does not change the outcome but the location of the infection from a predominantly soft tissue infection to a deeper bone and intramedullary (IM) channel infection. The debridement of the IM channel could potentially reduce the infection burden by eliminating those bacteria not easily reached by systemic antibiotics, though is not practical using conventional techniques

Prosthetic joint infections (PJI) caused by Streptococcus species are relatively common. The aim of our study was to assess outcome after treatment for early and late PJI with Streptococcus species after a follow-up of two years. For this study we retrospectively included all patients with primary or revision total knee arthroplasty (TKA) or total hip (THA) arthroplasty, a minimum of two periprosthetic tissue cultures positive for Streptococcus species and a minimum follow-up of one year. According to international guidelines patients were classified as having early or late PJI. All patients with an early PJI were treated according to a standard treatment protocol, i.e. debridement and retention of the prosthesis, followed by adequate antibiotic therapy. Patients with late PJI underwent a debridement followed by adequate antibiotic therapy or joint revision. Patients’ hospital records were reviewed and we evaluated the status of the original prosthesis after an infection. Forty cases were included; 24 early and 16 late PJI. For early PJI, open debridement was performed in all patients, after a mean of 19 (range: 9 – 80) days. At final follow-up 21 prostheses (88%) were still in situ and without clinical signs of infection. Eight cases (41%) of late PJI were successfully treated with debridement and retention. Nine patients (59%) underwent a one- or two-stage revision. At final follow-up 16 patients (100%) with late PJI had a prosthesis in situ. Streptococcus dysgalactiae species accounted for more than 50% of the early infections, followed by Streptococcus agalactiae with 30%. In case of PJI with Streptococcus species open debridement and retention of the prosthesis should be performed followed by adequate and long-term antibiotic treatment. As expected, the retention rate for early PJI is much higher than that for late PJI

Aim. Acute hematogenous periprosthetic joint infection (AHI) is a diagnosis on the rise. The management is challenging and the optimum treatment is not clearly defined. The purpose of this study was to evaluate the characteristics of AHI, and to study risk factors affecting treatment outcome. Methods. We retrospectively analysed 44 consecutive episodes with AHI in a total hip or knee arthroplasty beween 2013 and 2020 at a single center. AHI was defined as abrupt symptoms of infection ≥ 3 months after implantation in an otherwise well functioning arthroplasty. We used the Delphi criteria to define treatment failure with a minimum of 1-year follow-up. Results. AIH was most often caused by Staphylococcus aureus (36%) and streptococcal species (32%), but a broad spectrum of microbes were identified. The majority of patients (25/44) were treated with debridement and retention of the implant (DAIR), with a success rate of 40%, significantly lower than in patients treated with removal of the implant (94%, p=0.001). Staph aureus infections (p=0.004), knee arthroplasties (p=0.03), and implant-age < 2 years (p=0.034) were associated with treatment failure. The 2-year mortality rate was 19%. Conclusions. The main findings in this study were that outcome following DAIR in AHIs is poor, that the majority of infections were caused by virulent microbes, and we found a high mortality rate. Removal of the implant should more often be considered

Purpose. The success rate of surgical debridement and prostheses retention for acute periprosthetic joint infection (PJI) is controversial. This study aims to report our experience in managing acute PJI following total knee arthroplasty (TKA) with surgical debridement and prostheses retention, and to identify the prognostic factors that may influence the surgical outcomes. Methods. A retrospective review from our prospective joint replacement register in Queen Mary Hospital, Hong Kong, of patients who were managed with surgical debridement and prosthesis retention for acute PJI after TKA between 1998 and 2013 was performed. The diagnosis of acute PJI was based on the 2011 Musculoskeletal Infection Society (MSIS) PJI diagnostic criteria. Both the early post-operative infections and the late haematogenous infections were included (Tsukayama type 2 and 3). Surgical outcomes were defined as successful if patients’ clinical symptoms had been relieved; inflammatory marker levels including C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR) and White Blood Cell (WBC) count had returned to normal; X-rays showed no prosthetic loosening; and no lifelong antibiotic suppression was required. Outcomes were defined as failed if patients required any further surgeries (e.g., re-debridement, one or two-stage revision), or needed lifelong antibiotic suppression. All Patients’ perioperative data, i.e., age, primary diagnosis, pre-operative CRP, ESR, WBC, haemoglobin, albumin, glucose level, time lag from symptoms onset to debridement, synovial fluid total cell count and bacteriology were traced and recorded. SPSS 22.0 was used to calculate and compare the statistical differences between surgically successful group and failed group regarding the factors above. Results. 34 patients with 35 TKAs were included. There were 19 female and 15 male. The primary diagnoses included 29 osteoarthritis (OA) and 5 rheumatoid arthritis (RA). 8 had history of diabetes mellitus (DM). 25 knees received primary TKA and 10 knees received revision TKA, including 6 revisions for PJI and 4 for aseptic loosening. 12 belonged to Tsukayama type 2 (early post-operative infection) and 23 belonged to Tsukayama type 3 (late haematogenous infection). During a mean follow-up time of 45.9±44.2 months, 12 were successfully treated while 23 failed, including 15 required re-operations and 8 needed lifelong antibiotic suppression. The success rate of debridement was 34.2%. Statistical analyses showed no significant differences between the two groups on patients’ age, time lag from symptoms onset to debridement, pre-operative CRP, ESR, WBC, haemoglobin, albumin, glucose level or synovial fluid total cell count. (Table 1) Patients’ primary diagnosis, previous revision surgeries or staphylococcal infections had no significant impacts on the surgical outcome, either. Debridement with polyethylene insert exchange, however, had a significantly higher success rate than debridement alone. (Table 2). Conclusions. We concluded that debridement with prosthesis retention has a low success rate for acute periprosthetic infection in TKA. No significant prognostic factors could be identified, except that debridement with polyethylene insert exchange has higher success rate than debridement alone

Introduction. Urinary catheterisation can cause bacteraemia and therefore may be associated with a risk of infection in hip and knee arthroplasty. However postoperative urinary retention can be distressing for the patient. This study investigates the factors that might predict the need for postoperative catheterisation in order to help develop a protocol to decide who should be electively catheterised. Methods. A prospective blinded study of 128 consecutive patients undergoing lower limb arthroplasty was carried out. No patient underwent perioperative catheterisation. Data obtained included sex, age, joint (hip or knee replacement), prostate score (IPSS), previous urinary retention, comorbidities and residual bladder volume after attempted complete voiding measured using an ultrasound bladder scanner. The type of anaesthesia and the requirement for urinary catheterisation postoperatively were recorded. Predictive risk factors were identified using binary logistic regression, and expressed as odds ratios (OR) and 95% confidence intervals (CI). Results. The mean age was 69.5 years (SD 8.9). There were 56 males and 72 females. 38 patients (30%) required postoperative catheterisation. Logistic regression identified the following predictive risk factors: bladder scan volume per ml increase (OR 1.006; CI 1.000–1.012); male sex (OR 5.51; CI 2.01–15.16); previous catheter (OR 4.26; CI 1.53–11.82); spinal/epidural/combined spinal epidural (CSE) anaesthesia (OR 6.78; CI 1.75–26.32); moderate IPSS score (OR 5.15; CI 1.73–15.37); severe IPSS score (OR 3.53; CI 0.605–20.54). The specificity of our model is 91%, the positive predictor value 71% and negative predictor value 82%. Discussion. Post-voiding bladder scan volume (1ml increase = 0.6% increased risk), male sex, history of retention, medium or high IPSS score and an epidural, spinal or CSE anaesthetic are independent risk factors that can be used preoperatively to predict the likelihood of postoperative retention

Simulated learning is increasingly prevalent in many surgical training programs as medical education moves towards competency based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated diagnosis where the standard of care in patients less than six months of age is an orthotic device such as the Pavlik Harness. However, despite widespread use of the Pavlik Harness and the potential complications that may arise from inappropriate application, no formal educational methods exist. A video and model based simulated learning module for Pavlik Harness application was developed. Two novice groups (residents and allied health professionals) were exposed to the module and at pre-intervention, post-intervention and retention testing were evaluated on their ability to apply a Pavlik Harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skill (OSATS) and a Global Rating Scale (GRS) specific to Pavlik Harness application. A control group who did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik Harness alone would affect ability. All groups were compared to a group of clinical experts who were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t-tests and ANOVA. Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik Harness (p<0.05) to the level of expert clinicians and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve nor did they achieve competency. The simulated learning module has been shown to be an effective tool for teaching the application of a Pavlik Harness and learners demonstrated retainable skills post intervention. This learning module will form the cornerstone of formal teaching for Pavlik Harness application in developmental dysplasia of the hip

Introduction. Dual mobility (DM) implants provide increased stability and range-of-motion through the use of a large diameter mobile liner articulating against an acetabular shell. However, recent studies have reported that such contemporary large head prostheses can directly impinge against the local soft tissues leading to anterior hip pain. To address this drawback, a novel Anatomically Contoured Dual Mobility (ACDM) liner was developed that maintains the outer spherical geometry over an approximately hemispherical portion and then contours inward the distal profile of the DM liner for soft-tissue relief. The extent of the inner profile encapsulating the small diameter head is increased to provide more coverage of the head and maintain the inner head pullout force. We hypothesized that the ACDM liner for soft-tissue relief would not affect retention of the small diameter inner head or liner-acetabular load-bearing contact area. Methods. A finite element model to evaluate head retention and contact mechanics was created with a rigid acetabular shell, a plastically deformable UHMWPE DM liner, a rigid femoral head and a rigid femoral stem. For the head retention analysis, the extent of head coverage (Fig. 1) was optimized to match the inner head pullout force of a conventional DM liner. Contact mechanics of a conventional DM and ACDM liner were analyzed at the maximum joint load of three activities: gait, deep-knee bend and chair sit. One set of simulations was completed with the mobile liner and head axes aligned and another with the axes mal-aligned so that the mobile liner rim was adjacent to the femoral stem neck and the potential area of contact was away from the mobile liner apex. This allowed a broader range of potential contact to be assessed including what was determined to be a worst-case alignment. Results. The head extraction force of the conventional mobile liner with 224° of coverage was 909 N (Fig. 2). The ACDM liner with 232° of head coverage and an 8 mm reduced radius had an inner head extraction force of 901 N. The contact simulation results were practically identical for the ACDM liner and the conventional DM liner. Contact stresses between the two designs differed by less than 3.6%. In most cases, contact area (Fig. 3) was virtually equal with a slightly higher contact area in the ACDM (∼6.3%). In two of three worst-case liner orientations, the contact area between the shell and liner was found to be slightly lower for the ACDM liner (∼15%). The contact area and its distribution in all cases were found to be sufficient. Conclusion. This study showed that the novel anatomically contoured dual mobility liner maintains adequate inner head retention and articular contact area. The ACDM liner matched the head retention capacity of the conventional DM by slightly increasing the coverage of the inner head. The ACDM articular contact area was comparable to that of a conventional DM and satisfactory in all cases. These results demonstrate that a soft-tissue friendly design can be achieved while providing adequate head retention and load-bearing contact area

Reoperation on the acetabular side of the total hip arthroplasty construct because of acetabular liner wear with or without extensive osteolysis is the most common reoperation performed in revision hip surgery today. The options of revision of the component or component retention, liner exchange (cemented or direct reinsertion) and bone grafting represent a classic surgeon dilemma of choices and compromises. CT scanning is helpful in determining the size and location of osteolytic lesions. My preference is to retain the existing shell when possible especially when there are large osteolytic lesions but where structural support is maintained. The advantages of complete revision are easy access to lytic lesions, ability to change component position and the ability to use contemporary designs with optimal bearing surfaces (for wear and dislocation prevention). The disadvantage is bone disruption including pelvic discontinuity with component removal (less so with Explant Systems) and difficult reconstructions due to excessive bone loss from the osteolytic defects (sometimes requiring cup cages). The advantage of component retention is that structural integrity of the pelvis is maintained and in general, a higher quality polyethylene is utilised. For large lesions I use windows to debride and bone graft the lesions. If the locking mechanism is inadequate, cementing a liner, including a constrained liner in some cases, that has been scored in a spider web configuration provides durable results at 5-year follow-up. The downside to liner exchange is potential instability. We immobilise all liner exchange patients postoperatively

This retrospective study evaluates the outcome of patients with a late infection of a cemented total hip arthroplasty (THA) treated with two-stage revision with retention of the original well-fixed femoral cement mantle. Operation reports of all two stage revision performed in our clinic between 2009 and 2013 were reviewed (249 patients). Patients in which femoral cement mantle was retained during surgery were included (10 patients). The average age at the first stage revision procedure was 61.5 years (range 38–80). The mean follow-up period was 26 months (range 5 to 54 months). Clinical, laboratory, and radiological outcomes were evaluated. Successful treatment of periprosthetic joint infection (PJI) was achieved in six out of 10 patients; four patients showed no signs of infection during follow-up. Two of these patients received three months of antibiotic treatment after second stage, because of positive cultures at second stage. The other two successfully treated patients showed recurrence of PJI one week after second stage. Debridement with retention of prosthesis (DAIR) was performed. Newly cultured microorganisms were successfully treated with 3 months of antibiotics. The other four patients were considered to be failures; in three patients, the femoral cement mantle was removed after the first stage due to recurrent infection. The other failure showed a recurrent PJI after second stage. Despite DAIR and three months of antibiotic treatment, this patient is treated with suppressive antibiotics until latest follow-up. Based on this study, results in managing an infected THA with cement-within-cement revision are disappointing. Therefore, more research is required to determine which patients are appropriate for cement-within-cement revision

Purpose. Two-stage revision with the removal of all prosthesis has been considered to be the gold standard for treatment of periprosthetic joint infection. However, removal of well-fixed femoral stem is technically challenging and may cause excessive bone loss. The aim of this study was to compare the results between retention and removal of femoral stem when performing two-stage revision total hip arthroplasty for periprosthetic joint infection. Materials & Methods. From 2007 to 2014, ninety-four patients with infection after hip arthroplasty were treated by using two-stage exchange protocol with temporary articulating spacers. Among them, 38 patients completed the planned second stage reimplantation. Stem was exchanged in 15 patients (group I) and retained in 23 patients (group II). We retrospectively investigated the clinical and radiographic results after an average 39.9 months follow up. Results. The rate of infection control was 86.6% (13/15) in group I, 86.9% (20/23) in group II. There were no statistical differences between the two groups in term of demographics or presence of resistant organism. Conclusion. Retention of well-fixed cementless stem during two-stage revision total hip arthroplasty could be alternative treatment option for the treatment of periprosthetic joint infection

Aim. Debridement and implant retention (DAIR) is a valuable option for treating periprosthetic joint infection (PJI), provided that the criteria of the Infectious Diseases Society of America guidelines are fulfilled. The inflammation caused by infection and the surgical impact of DAIR may influence implant stability. In this study, we investigated the sequelae of DAIR on implant survival after total hip arthroplasty (THA). Method. THAs from our database implanted between 1984 and 2016 were included in a retrospective double-cohort study. THAs were exposed (DAIR cohort) or not exposed to DAIR (control cohort). The control cohort comprised patients matched 3:1 to the DAIR cohort. The outcome—implant failure over time—was evaluated for (i) revision for any reason, (ii) aseptic loosening of any component, and (iii) radiographic evidence of loosening. Results. Fifty-seven THAs (56 patients) were included in the DAIR cohort and 170 THAs (168 patients) in the control cohort. The mean follow-up periods in the DAIR and control cohorts were 6.1 (SD 4.7) and 7.8 (SD 5.5) years, respectively. During follow-up, 20 (36%) patients in the DAIR cohort and 54 (32%) in the control cohort died after a mean of 4.1 (SD 4.7) and 7.2 (SD 5.4) years, respectively. Revision for any reason was performed in 9 (16%) DAIR THAs and 10 (6%) control THAs (p = 0.03) and for aseptic loosening of any component in 5 (9%) DAIR THAs and 8 (5%, p = 0.32) control THAs, respectively. Radiological analysis included 56 DAIR THAs and 168 control THAs. Two (4%) stems and 2 (4%) cups in the DAIR cohort and 7 (4%) and 1 (0.6%) in the control cohort, respectively, demonstrated radiological signs of failure (p = 1). Conclusions. THAs exposed to DAIR were revised for any reason more frequently than were THAs in the control cohort. The difference in revisions for aseptic loosening was not statistically significant. There was no statistically significant difference in radiographic evidence of loosening of any component between cohorts

Urinary catheterization in the postoperative period is known to increase the risk of deep joint infection following arthroplasty. A number of studies have attempted to elucidate the individual patient factors and surgical procedural factors which predispose patients to postoperative urinary retention. We conducted a retrospective observational study of three hundred patients to specifically determine the effect of the anaesthetic technique on the incidence of urinary retention following elective lower limb arthroplasty. One hundred consecutive patients were surveyed in each of three groups differing by the type of the anaesthetic technique and the drug administered; 1) general anaesthesia with femoral nerve block, 2) spinal anaesthesia with intrathecal fentanyl, and 3) spinal anaesthesia with intrathecal morphine. The incidence of urinary retention requiring catheterisation in male patients receiving intrathecal morphine was 58% compared with 10% and 6% for those who had general anaesthesia with femoral nerve block and intrathecal fentanyl, respectively. This difference was statistically significant (p<0.01). The incidence of urinary retention in females across all groups was =2%. The average residual volume of urine following catheterisation was 750ml (460-1500ml). Our findings show that the use of intrathecal morphine greatly increases the risk of postoperative urinary retention in male patients, whereas no significant increase was found amongst female patients. This risk should be carefully considered when choosing the type of intraoperative anaesthetic/analgesic combination employed in male patients and be rationalised against the intended benefits to the patient

OBJECTIVE. Debridement, Antibiotics and Implant Retention (DAIR) procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our perspective of DAIR in a relatively a small cohort following hip and knee replacements in a District General Hospital (DGH) in United Kingdom, where we delivered comparable results to leading tertiary centers in short to mid-term followup. METHODS. We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Multiple samples were taken intraoperatively for cultures and histology. mMicrobiological support was provided by a microbiologist with interest in musculoskeletal infections. RESULTS. 14 patients [9 males, 5 females; age 62–78 years (Mean 70.7); BMI 22–44.2 (Mean 33.8)] with multiple comorbidities underwent DAIR procedure within 3 weeks of onset of symptoms, (although the time from index surgery ranged from 15 days to 58 months). Patient selection was made by two Hip surgeons. 12 out of 14 grew positive cultures with two growing Vancomycin resistant Enterococcus. IV antibiotics were stated after samples intraoperatively and continued in six patients after discharge using (OPAT), while 8 were discharged with oral antibiotics. One patient died in immediate post operative period due to generalised sepsis. Another patient died of myocardial infarction 2 years after DAIR. 12 (85.7%) patients are doing well with regular followup (Mean 20 months) in clinics. CONCLUSIONS. With good patient selection, DAIR is a far simpler solution and a safe and reproducible surgical option in PJI in hip and knee replacements compared to one or two stage revisions with the implications. But published Data in contemporary literature is predominantly from specialized centers. Our small series provides a perspective of early to mid term results of DAIR from a DGH

Periacetabular osteolysis is seen in response to particles (polyethylene, ceramic, metal or cement), at times in the presence of an unstable implant, and perhaps made worse by the unique host response to the particle burden. The impact of wear modes: due to either the primary bearing surface (MOP, MOM, COC) or unintended surfaces as seen in impingement, as well as the quality of the bearing counterface all influence the extent of the osteolytic response. The final common pathway appears to be via macrophage stimulation, an upregulation of cytokines leading to a resorption of bone. The patterns of lysis range from linear resorption at the implant interface to more expansile patterns which can be more dramatic in size and may place the implant at jeopardy for loosening. Assessment of implant fixation as well as extent of the lytic process employs the use of plain radiographs (including oblique views), computerised tomography and magnetic resonance imaging. The utility of MRI for the quantification of bone loss as well as the newer phenomena of associated soft tissue lesions (pseudotumors, adverse tissue reactions) has turned out to be a valuable tool in helping determine timing and need for revision. The basic principles in determining need for revision surgery revolve around: degree of lysis, integrity of the soft tissues, fixation of the implant, track record of the implant, as well as patient factors including symptoms, age and activity. In cemented sockets, progressive bone loss, pain with or without overt loosening is indication for revision which is generally accomplished using an uncemented hemispherical acetabular component with bone graft and screw augmentation. In the uncemented socket, the decision to revise is based upon a) implant stability, 2) the integrity of the locking mechanism, 3) degree of bone loss. With stable implants, polyethylene exchange and “lesional” treatment is appropriate. Well fixed implants with extensive lysis can be successfully managed with liner exchange and bone grafting as necessary. If the liner locking mechanism is compromised, cementing a liner into place is an excellent strategy. Removing a well fixed cup with extensive lysis runs the risk of encountering a large acetabular defect which may be difficult to reconstruct. Loose implants clearly require revision. In the era of “hard bearings”, progressive soft tissue expansion leading to damage of the abductor and other soft tissue constraints about the hip is an indication for revision. Revision of MOM THR's may be performed by maintaining the femoral component and performing an isolated acetabular revision or in some instances of modular acetabular components, maintaining the shell and inserting a new liner. In all instances of implant retention, it is critical to confirm that the components are in optimised position: implants retained in suboptimal position are at risk for early failure

Urinary catheterisation may be associated with a risk of infection in hip and knee arthroplasty, however post-operative urinary retention can be distressing for the patient. This study investigates the factors that might predict the need for post-operative catheterisation. A prospective blinded study of 128 consecutive patients undergoing lower limb arthroplasty was carried out. Data obtained included sex, age, joint (hip or knee), prostate score (IPSS), previous urinary retention, co-morbidities and residual bladder volume after attempted complete voiding measured using an ultrasound bladder scanner. Anaesthetic type and requirement for urinary catheterisation postoperatively were recorded. Predictive risk factors were identified using binary logistic regression, and expressed as odds ratios (OR) and 95% confidence intervals (CI). The mean age was 69.5 years. There were 56 males and 72 females. 38 patients (30%) required post-operative catheterisation. Logistic regression identified the following predictive risk factors: bladder scan volume per ml increase (OR 1.006; CI 1.000–1.012); male sex (OR 5.51; CI 2.01–15.16); previous catheter (OR 4.26; CI 1.53–11.82); spinal/epidural/combined spinal epidural anaesthesia (OR 6.78; CI 1.75–26.32); moderate IPSS score (OR 5.15; CI 1.73–15.37); severe IPSS score (OR 3.53; CI 0.605–20.54). Our model specificity is 91%, positive predictor value 71% and negative predictor value 82%

The clinical guidelines for hip fracture management indicate that indwelling foley catheterization should be avoided when possible. Alternatives to indwelling catheters such as intermittent or condom catheters are recommended. Appropriate catheterization usage is important in hip fracture patients to avoid complications such as urinary tract infections (UTIs) (7–24% of patients) or post-operative urinary retention (POUR) (20–56% of patients). In this study, we aim to, (1) evaluate catheter usage in hip fracture patients at a large tertiary care centre, (2) compare current practices in catheter usage to clinical guidelines, (3) determine the incidence of POUR in hip fracture patients (4) determine the factors that increase one's risk of developing POUR. We analyzed 584 hip fracture patients between the ages of 18 and 102 admitted between November 2015 and October 2017 at a tertiary Care Hospital. Data collected included patient demographics, fracture pattern, surgical procedure, length of stay, co-morbidities and catheter use. We compared actual catheter usage to suggested guidelines to determine whether recommendations were being followed. We also investigated the incidence of POUR and risk factors associated with developing POUR. Independent samples t-test were used to compare continuous dependent variables in bivariate analyses and a logistic regression was used to determine predictors of developing POUR, catheter usage, and length of stay in multivariate analyses. T. Over three quarters (76.9%) of patients with hip fractures were treated with a catheter during their admission, 63.5% of which were inserted pre-operatively and 36.5% of which were inserted post-operatively. Indwelling catheters accounted for 92.2% of catheters used, while intermittent and catheter condoms accounted for 7.8%. POUR occurred in 98 of 584 cases (16.7%). Age (p = 0.004), gender (p=0.001), and presence of kidney disease (p=0.033) were statistically significant predictors of POUR. Fracture pattern (p=0.825), surgical procedure (p=0.298), diabetes mellitus (p=0.309) and UTI in the past 60 days (p=0.848) or on admission (p=0.999) were not statistically significant predictors of developing POUR. The development of POUR did not significantly increase length of stay (p=0.558). There was no statistically significant correlation between developing POUR and extended post-operative catheter use over 24 hours (p=0.844) or 48 hours (p=0.862). Patients who received a catheter pre-operatively or post-operatively for longer than 24 hours were not significantly more likely to develop POUR (p=0.057). Catheter use was common for all hip fracture patients and indwelling catheters were used in the overwhelming majority of cases. The high frequency of catheter usage, and specifically indwelling catheter usage, suggests that there is low compliance with the clinical guidelines for hip fracture patients. The incidence of POUR was 17%. Older, male patients were more likely to develop POUR. Although not statistically significant, more appropriate catheter use may decrease urinary complications such as POUR

Introduction. Success rate after Debridement-Irrigation, Antibiotic Therapy and Implant Retention (DAIR) for treatment of Acute Haematogenous (AH) and Early Post-surgical (EP) periprosthetic joint infection (PJI) varies widely among published studies. Prosthesis exchange is recommended to treat PJI after a failed DAIR. However, no early postoperative prognostic factors permitting to identify future failures have been described. Aim. Identify early prognostic factor of failure after DAIR in order to propose efficient treatment before onset of chronic PJI. Hypothesis. Positive suction drainage fluid culture is a strong early predictive factor of failure. Methods. We conducted a retrospective study, with a minimum 2 years follow-up. Twenty-two consecutive patients (78 years-old +/-10) with EPPJI: i.e. infection within 1 month after joint replacement (n=12; 55%) or AHPJI: i.e. acute haematogenous infection with less than 2 weeks evolution (n=10; 45%) were included. The involved prostheses were: Total Knee Arthroplasty (n=12; 55%), Total Hip Arthroplasty (n=7; 32%) and Hip Hemi-Arthroplasty (n=3; 14%). DAIR was indicated for each patient. Suction drainage fluid was systematically analysed at day 1, 3 and 5 postoperative. Failure of the procedure was defined as: need for iterative surgery to control PJI or suppressive antibiotherapy to control PJI or death related to PJI. Results. At 2 years follow-up, failure rate after DAIR was 55%. Only positive suction drainage fluid culture was statistically associated with treatment failure (p=0,039). Neither type of prosthesis: knee prosthesis vs hip prosthesis (Odds Ratio (OR)=1; IC95%[0.14; 7.21]) nor type of fixation : cemented vs uncemented prothesis (OR=4,39; IC95%[0.29; 269]) were associated with treatment failure. In addition, type of bacteria causing PJI and especially S. aureus (OR=3,1; IC95%[0.42; 28.61]), type of infection (OR= 1,47; IC95%[0.21; 11.37]), delay between onset of symptoms and DAIR (OR= 1,63; IC95% [0.21; 14.85]) or retaining of modular component (OR= 1.32; IC95% [0.17; 10.59)) were not associated with a higher rate of failure. Conclusion. Positive suction drainage fluid culture could be an early postoperative predictive factor of failure after open Irrigation-Debridement, Antibiotic Therapy and Implant Retention for EPPJI and AHPJI

Prosthetic joint infections (PJI) are caused by a variety of microorganisms but most frequently by staphylococci. The results of treatment of PJI due to organisms other than staphylococci are less known. The aim of this study is to evaluate the outcomes after streptococcal PJI. The data of 26 streptococcal (13 hip and 13 knee PJI from 24 patients) were retrieved from hospital based PJI register, and analyzed. There were 15 female and 11 male patients (mean age 66 y). Most (13) PJI were hematogenous. 15 PJI had been treated with debridement and retention (D&R) of the infected joint, 1 with permanent resection arthroplasty, 9 had two stage revision and 1 patient had one stage partial replacement. After the microbiological diagnosis was established most patients received 2–3 weeks of penicillin G or ceftriaxone followed by 2–6 months of oral amoxicillin. All patients had regular follow-ups after the procedure at least at 1 month, three months and one year. The results were classified as: PJI cure (in absence of clinical signs and symptoms of infection and with negative CRP), probable failure (in absence of clinical signs and symptoms of infection but with elevated CRP), definite failure (if a new treatment was necessary), and mechanical failure (aseptic loosening, periprosthetic fracture, quadriceps rupture). One foreign patient was lost to follow up. The mean follow up time for the rest was 60 months (from 16 to 167) months. There was probable prosthesis failure in 1 case, definite prosthesis failure in 7 cases and mechanical failure in 3 cases. The mean survival time of the failed prostheses was 28 (range from 2 to 83) months. 6 failures (40 %) occurred in group of cases that had undergone D&R, and 1 (6 %) in the two stage revision group. Among the 7 definite failures in 4 patients antibiotic treatment was empirically started after the symptoms reappeared resulting in long remission periods. Comparing to the published results of staphylococcal PJI it seems that D&R of the prosthesis for streptococcal PJI is considerably less successful. Rifampicin as a proven treatment of choice for staphylococcal infections is probably the main reason for the difference. An unexpected feature of streptococcal PJI is that definite failures are easily suppressed for long time with a short course of oral antibiotics