Aim. The prevalence of unexpected positive cultures (UPC) in aseptic revision surgery of the joint with a prior septic revision procedure in the same joint remain unknown. The purpose of this study was to determine the prevalence of UPC in aseptic revisions performed in patients with a previous septic revision in the same joint. As secondary outcome measure, we explore possible risk factors associated with UPC and the re-revision rates. Method. This retrospective single-center study includes all patients between January 2016 and October 2018 with an aseptic revision total hip or knee arthroplasty procedure with a prior septic revision in the same joint. Patients with less than three microbiology samples, without joint aspiration or with aseptic revision surgery performed <3 weeks after a septic revision were excluded. UPC was defined as a single positive culture in a revision that the surgeon had classified as aseptic according to the 2018 International Consensus Meeting. Results. A total of 139 revision total hip/knee arthroplasties in patients with a previous septic revision were performed during the study period. After excluding 47 cases with insufficient information, a total of 92 patients were recruited for final analysis. The patient cohort consist of 52 males and 40 females with a mean age of 70 years (±10.6). There were 66 (71.7%) hips and 26 (28.3%) knees. The mean time between the septic and the aseptic revision was 83 months (±89). The two main causes for the aseptic revision were aseptic loosening (n=57, 62%) followed by instability (n=21, 22.9%). We identified 11 (12%) UPC in the entire cohort, while in 3 cases there was a concordance of the germ compared to the previous septic surgery. There were no differences for the presence of UPC between hips and knees (p=0.282), diabetes (p=0.701), immunosuppression (p= 0.252), previous one-stage or two-stages septic revision (p=0.316), or between the causes for the aseptic revision ((p=0.429). There was no correlation between the UPC and time after the septic revision (p=0.773). Conclusions. The prevalence of UPC in this specific group was similar to those reported in the literature for aseptic revisons. More studies, regarding this patient group are necessitated to better understand and more securely interprete the results in those high-risk aseptic revisions

Aim. Antimicrobial resistance (AMR) aggravates an already difficult treatment of periprosthetic joint infections (PJI). The prevalence of drug-resistant pathogens varies across countries and increases over time. Regular monitoring of bacteriological analyses should be performed. Due to many factors influencing the AMR, the correct choice of antimicrobial management remains arguable. The primary purpose of this retrospective study was to identify and compare causative bacteria and to compare the incidence of antibiotic resistance between the septic revision total knee arthroplasty (TKA) and septic revision total hip arthroplasty (THA). Method. A review of all revision TKAs and revision THAs, undertaken between 2007 and 2020 in a tertiary referral centre, was performed. Included were cases meeting the consensus criteria for PJI, in which an organism has been identified. There were no major differences in tissue sampling between revision TKAs and revision THAs over time. Results. A total of 228 bacterial strains, isolated after revision TKA and THA, were analysed for their resistance to 20 different antibiotics. There was a statistically significant higher occurrence of Gram-negative bacteria (p=0.002) and Enterococcus species (p=0.026) identified after revision THAs compared to TKA. The comparison of antibiotic resistance between revision TKAs and revision THAs was statistically significant in 9 of 20 analysed antibiotics. Pathogens isolated after revision THA were much more resistant compared to pathogens isolated after revision TKA. Resistance in revision THAs was significantly higher to oxacillin (p=0.03), ciprofloxacin (p<0.001), levofloxacin (p<0.001), moxifloxacin (p=0.005), clindamycin (p<0.001), co-trimoxazole (p<0.001), imipenem (p=0.01), rifampicin (p=0.005) and tetracycline (p=0.009). There was no significantly higher resistance of pathogens isolated after revision TKAs detected. No statistically significant difference in antibiotic resistance of Gram-negative bacteria between revision TKA and revision THA was observed. Conclusions. The occurrence and the resistance of bacteria to antibiotics differs significantly between revision TKAs and revision THAs. This has implications on of the choice of empirical antibiotic in revision surgery as well as prophylactic antibiotic in primary surgery, depending on the joint that is to be replaced

Introduction. Polymicrobial infections are expected to complicate the treatment of bone and joint infections. Septic nonunions often occur after initial open fractures, which prophylactically receive broad-spectrum antibiotics. However, no data that describes frequencies of polymicrobial infections and pathogens evident in course of the treatment of septic nonunions is published. Therefore, this study aims at investigating the frequency and pathogen types in polymicrobial infections. Methods. Surgically treated Patients with long bone septic nonunion admitted between January 2010 and March 2018 were included in the study. Following parameters were examined: age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and anatomical location of the infected nonunion. Microbiological culture data, polymerase-chain-reaction results of tissue samples, sonication, and joint fluid of the initial and follow-up revision surgeries were assessed. No exclusion criteria were determined. Results. The study encompassed 42 patients with a mean age of 53.9 ± 17.7 years (range, 23 – 93). Sixteen (38.1%) patients were female. In 46.3% of the patients open fractures led to septic nonunion. Twenty-six nonunions occurred at the tibia or fibula, 11 were localized at the femur, 2 at the humerus and 3 at the forearm. Only 2 patients were assessed as ASA type 1, while 26 were ASA type 2 and 12 patients ASA type 3. Mean number of performed surgeries was 6 ± 0.67 (range 2 – 21). In 6 patients (14.3%) polymicrobial infection were evident. A change of evidenced pathogens in course of the treatment occurred in 21 patients (50%). In 16 patients (38.1%) previously detected bacteria could be evidenced by microbial testing after further revision surgery. Staphylococcus aureus was most often evident (n=34, 30.6%), followed by Enterococcus species (n=25, 22.5%) and Staphylococcus epidermidis (n=18, 16.2%). Five Staphylococcus aureus were resistant to methicillin (MRSA). In patients without polymicrobial infection or further germ detection in course of the treatment 86.4% of the infections were due to Staphylococcus species. Patients with change of detected pathogens and polymicrobial infections suffered from more enterococci infections. Infections due to streptococci and gram-negative bacteria could only be evidenced in patients with polymicrobial infection and pathogen change in course of the treatment. Conclusion. The observed difference of microbiological patterns in septic nonunion may help to facilitate adjuvant local and systemic antibiotic treatment in septic nonunion patients. Reasons for the observed difference of microbiological patterns and its influence on patient outcome have still to be elucidated

Aim. Bone loss is a severe problem in septic revision total knee arthroplasty (RTKA). The use of porous coated metaphyseal sleeves is a promising treatment option for extended bone defects. The currently published mid-term results remain limited and no study has been focused exclusively on septic cases. Our aim was to determine the implant survivorship (with special focus on osseointegration) and the clinical and radiological mid-term outcome of metaphyseal sleeve fixation in septic RTKA surgery (minimum follow-up of 2 years). Method. Between January 2005 and September 2015, 57 patients underwent septic RTKA surgery using metaphyseal sleeves. In 56 patients (98,2 %) who underwent a total of 69 two stage revision procedures, clinical and radiological follow-up examinations were conducted. One patient (1,8 %) was lost to follow-up. The examinations included the American Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the SF-36 Health survey as well as radiographic measurement to determine if successful osseointegration had been achieved. Results. Thirteen knees (18.8%) had to be re-revised at the time of follow-up (mean 5.3 years, min. 2 – max. 11.2), all due to reinfection (Figure 1). We did not encounter any cases of aseptic loosening. The mean range of motion (92° ± 21°), SSS (7 ± 2), KSS (76 ± 19), WOMAC (70 ± 20), SF-36 MCS (55 ± 14) and SF-36 PCS (35 ± 9) have shown satisfying results. Conclusions. Metaphyseal sleeves have shown very promising mid-term results regarding clinical scores, osseointegration, and aseptic loosening. Our results are the first analysing the performance of metaphyseal sleeves in exclusively septic cases and show that they are a reliable fixation option in septic RTKA patients with severe bone loss

Introduction. Throughout the world the number of large joint arthroprosthetic implants continues to increase and consequently the number of septic complications with prosthesis mobilizations, periprostehtic bone loss or non-unions. The implant of large resection prosthesis (megaprosthesis) in selected patients could be a good solution both in hip and knee infected prosthesis with bone defects. The two stage techniques with a first operation to debride, prosthesis components removal and antibiotic spacer implantation followed by a subsequent final prosthetic implant offer great results even in highly complex patients. Objectives. The purpose of this study is to evaluate retrospectively the outcome after the implantation of megaprosthesis of the lower limbs in prosthetic infected revision. Methods. We have retrospectively evaluated all the patients we have treated with implantation of megaprosthesis in septic prosthesis revision. Between January 2008 and January 2014 we have treated 25 patients: 18 cases of hip revision and 7 cases of knee revision. All patients were treated with a two steps procedure. Results. We obtained good results from a clinical, laboratory and radiological point of view with restoration of the function of the affected limb in 22/25 cases. In 3/25 cases the infection recurred and an additional surgery was necessary. Conclusions. Megaprosthesis in large septic revision can be considered, in extreme cases appropriately selected, an available solution for the orthopedic surgeon able to restore function to the patient. The two steps procedure gives the best results with safety and lower infection recurrence creating a membrane (Chamber Induction Technique) that can protect the prosthesis in a safe environment. This type of complex surgery must be performed in specialized centers where knowledge and technologies are present

INTRODUCTION. Recently the evolution of prosthesis technology allows the surgeon to replace entire limbs. These special prostheses or megaprostheses were born for the treatment of severe oncological bone loss. Recently, however, the indications and applications of these devices are expanding to other orthopaedic and trauma situations. Since some years we are implanting megaprostheses in non-oncological conditions such as septic post-traumatic failures represented by complex non-unions and critical size bone defects. The purpose of this study is to retrospectively evaluate the clinical outcome of this treatment and register all the complications and infection recurrence. MATERIAL AND METHOD. Between January 2008 and January 2016 we have treated 55 patients with septic post-traumatic bone defects In 48/55 cases we perform a 2 steps procedure: 1° step: resection, debridment, devices removal and antibiotic spacer implantation; 2° step: spacer removal and megaprosthesis implantation. In 7/55 patients in whom all the femur was infected, we performed a one step procedure by the complete removal of the femur and a megaprosthesis (Total Femur) implantation. RESULTS. We obtained good results from a clinical, laboratory and radiological point of view with restoration of the function of the affected limb. Only in 5/55 cases the infection recurred. All the Total Femur megaprosthesis implanted in a one step procedure healed without recurrence of infection. CONCLUSION. Megaprosthesis in severe septic bone loss can be considered, in extreme cases appropriately selected, as an available solution for the orthopedic surgeon. The two steps procedure gives the best results with safety and lower infection recurrence creating a membrane (Chamber Induction Technique) that can protect the prosthesis in a safe environment. We can perform a one step procedure only when all the infected segment is entirely removed. This type of complex surgery must be performed in specialized centers where knowledge and technologies are present

Aim. Femoral or tibial massive bone defects (AORI F2B-F3 / T2B-T3) are common in septic total knee replacement. Different surgical techniques are described in literature. In our study we show clinical and radiological results associated with the use of tantalum metaphyseal cones in the management of cavitary bone defects in two-stage complex knee revision. Method. Since 2010 we have implanted 70 tantalum metaphyseal cones associated with constrained or semiconstrained knee prostheses in 47 patients. The indication for revision was periprosthetic knee infection (43 cases, 91.5%) or septic knee arthritis (4 patients, 8.5%) with massive bone defect. All cases underwent a two-stage procedure. Patients were screened for main demographic and surgical data. Clinical and radiological analysis was performed in the preoperative and at 3,6 months, 1 years and each year thereafter in the postoperative. The mean follow-up was 31.1 months ± 18.8. No dropout was observed. Results. Objective and subjective functional scores (KSS, OKS) showed a statistically significant improvement from the preoperative to last follow-up (p <0.001). All cones but one (98.6%) showed radiological osteointegration. We did not find any cone-related intraoperative or postoperative mechanical complication with a 100% survival rate when we consider aseptic loosening as cause of revision. Six non progressive radiolucencies were observed. Two septic failures (4.3%) with implant and cone removal were reported. Conclusions. The ideal treatment for cavitary bone defects in two-stage TKA septic revision is still unclear. The use of metaphyseal tantalum cones showed excellent clinical and radiographic results with a low rate of related complications. The main finding of our study is the cone-related infection rate (2.9%) in this particular series of patients. This data is comparable or better than other previous report about this topic with unhomogeneous cohort of patients

Aim. To improve the challenging treatment of periprosthetic joint infections (PJI), researchers are constantly developing new handling methods and strategies. In patients with PJI after total knee arthroplasty (TKA) and severe local or systemic comorbidities, a two-stage exchange using a temporary antibiotic loaded PMMA-spacer is considered gold standard. This method has undisputed advantages, however, the increased risk of biofilm formation on the spacer surface, bone defects and soft tissue contractions after a six-week spacer interval are severe limitations. Our hypothesis is that a vacuum sealed foam in combination with constant instillation of an antiseptic fluid can address these drawbacks due to a significantly reduced spacer interval. Method. A pilot study was conducted in five PJI cases after TKA with severe comorbidities and/or multiple previous operations to evaluate the feasibility and safety of the proposed method. In the first step, surgical treatment included the explantation of the prosthesis, debridement, and the implantation of the VeraFlo-Dressing foam. The foam is connected to the VAC-Instill-Device via an inflow and an outflow tube. The surgical site is sealed airtight with the VAC-film. During the next 5 days, an antiseptic fluid (Lavasorb® or Taurolidine®) is instilled in a 30-minute interval using the VAC-Instill-Device. The limb is immobilized (no flexion in the knee joint, no weight bearing) for five days. Following that, the second operation is performed in which the VAC-VeraFlo. TM. -Therapy System is explanted and the revision TKA is implanted after debridement of the joint. Results. No serious adverse event occurred during the VAC-Instill spacer treatment. The TKA revision was performed after a mean of 5.4 ± 1.9 days. Mean patient age was 71±6 years with a mean of 6 previous PJI surgeries. Host classification according to McPherson was I/B/3, III/B/3 and III/C/3 in three cases. Out of the five cases included, four were successfully treated and remained infect free to date (mean 14.2 ± 12 months; germs: methicillin-resistant s. aureus, e. coli, staph. lugdunensis and one culture neg.). One case with candida infection of a total femur prosthesis had to be treated with an enucleation of the hip due to rising inflammation parameters and signs of sepsis 7 days after VAC-Instill implantation. Conclusions. The presented data on the VAC-Instill spacer method in septic two-stage revision TKA show promising results regarding feasibility and safety. A prospective randomized controlled examination is in progress to evaluate the possible advantages over a two-stage approach using a standard PMMA spacer

To present the results achieved with the use of external fixation techniques in treating 52 cases of post-traumatic and post-surgical septic non-union in a low resources setting. From 2006 to 2014 52 patients were treated for post-traumatic septic non-union of the lower and upper limb bones. Clinical records and radiographs were reviewed; telephone interviews were done for patients unable to reach our institution. There were 39 males and 13 females, with an average age at the time of admission of 29 years (the youngest patient was 8 years old, the oldest 81). Tibia was involved in 43 cases (24 right side, 19 left side), femur in 9 (4 right, 5 left) and left humerus in 1. All the patients, except two, had been treated in other institutions before admission. At presentation, 19 patients had an external fixator in situ, 18 patients had infected osteosynthesis, 15 had exposed necrotic bone, with loss of soft tissues. In 20 cases hardware removal, debridement and sequestrectomy were followed by application of an external fixator. In 31 cases bone transport was done; the fixator was monolateral in 27 cases. In 1 case sequestrectomy and external fixation were followed by a vascularized fibula graft. Bifocal bone transport was utilized in one patient while the bone transport procedure was associated to limb lengthening in 10 patients. Plastic surgery was required in 13 patients. Rotational flaps, vascularized free flaps and extensive skin grafts were all used. The site of non union was cured in all the patients, in an average time of 11 months (from 4 to 32). Two patients required an amputation a few months after the end of the treatment. There was need for fixator adjustment and screws replacement in 21 patients. Non-union at the docking point was observed in 5 patients; it was septic in two of them. There was need of skin-plasty in 2 cases for skin invagination. In 3 cases an extensive skin ulcer was observed during the transport procedure. Limb length discrepancy was corrected in 10 patients. A residual limb shortening was observed in 14 patients. Ankle fusion, knee fusion, foot drop, sensory loss in the foot, reduced range of joint motion were also observed. The external fixator plays a pivotal role in the treatment of septic non unions, especially in low resources setting. The treatment is long and costly. Strict medical supervision is necessary during the entire process

Aim. One of the most challenging problems in total knee arthroplasty (TKA) is periprosthetic infection. A major problem that arises in septic revision TKA (RTKA) are extended bone defects. In case of extended bone defects revision prostheses with metaphyseal sleeves are used. Only a few studies have been published on the use of metaphyseal sleeves in RTKA - none were septic exclusive. The aim of our study was to determine the implant survival, achieved osseointegration as well as the radiological mid-term outcomes of metaphyseal sleeve fixation in septic two-stage knee revision surgery. Method. Clinical and radiological follow-up examinations were performed in 49 patients (25 male and 24 female). All patients were treated with a two-stage procedure, using a temporary non-articulating bone cement spacer. The spacer was explanted after a median of 12 weeks (SD 5, min. 1 – max. 31) and reimplantation was performed, using metaphyseal sleeves in combination with stem fixation. Bone defects were classified on preoperative radiographs using the Anderson Orthopaedic Research Institute (AORI) classification. During follow-up postoperative range of motion (ROM) was measured and radiographs were performed to analyse: (i) osseointegration (radiolucent lines and spot welds), (ii) leg alignment, (iii) patella tilt and shift. Results. All types of bone defects were found on the tibial (4× type 1, 7× type 2a, 26× type 2b, 9× type 3) as well as on the femoral side (1× type 1, 4× type 2a, 20× type 2b, 6× type 3). Mean follow-up time was 4.7 years (minimum 1 year). In total 12 knees (24.5%) had to be re-revised, all due to re-infection. We did not encounter any case of aseptic loosening. In 3 patients (6.8%) we detected an insufficient osseointegration, but no patient had to be re-revised due to only minimal or to the absence of symptoms and no clinical signs of loosening. The ROM (mean 93°, SD 20.6, min. 25° max. 125°) has shown very satisfying results at the time of follow-up. Malalignment was detected in 4 patients (10.3%), a patella tilt in 7 (19.4%) and a patella shift in 14 (48.3%). Conclusions. Metaphyseal Sleeves have shown very promising mid-term results regarding osseointegration and aseptic implant survival in RTKA with compromised metaphyseal bone stock. Our results indicate that they are a reliable fixation option in septic RTKA patients

Aim. Negative pressure wound treatment (NPWT) has been widely adopted in the management of septic wound complications or prophylactically after large surgeries. Recent publications have indicated the necessity of further investigations to support the use of NPWT with more evidences. Therefore, the purpose of this pilot-study was to investigate the efficacy of VAC-assisted dressing systems in the treatment of septic trauma cases. Method. We analysed data of 16 retrospective cases following traumas and septic soft tissue surgeries around the hip and knee. The collected data consisted of bacterial cultures, inflammatory markers (WBC, CRP/HCRP) and body temperature, taken periodically during treatment. Also recorded were the time periods the vacuum pump was used during treatment. To increase the number of measurements and to facilitate subsequent data analysis, the measurements were interpolated to regularly sampled curves with a sampling rate of one day. We used cross-plots and linear regression analysis to investigate trends in the data: 1) while the vacuum pump was switched on and 2) while it was switched off. Results. The analysis shows that the average WBC and CRP/HCRP values decline in the first days after initiation of the VAC treatment. WBC values decline in the first four days of VAC treatment (linear regression, R. 2. =0.960). CRP/HCRP values decline in the first thirteen days (linear regression, R. 2. =0.952). No meaningful trends were observed in body temperature measurements. Importantly, there is a trend for an increase of WBC and CRP/HCRP, following the 4. th. and 14. th. days, respectively. These findings suggest that the prolonged use of VAC treatment may result in secondary relapses. Conclusions. Our results indicate a marked decrease of inflammatory markers during the first two weeks, confirming the efficacy of NPWT in the management of septic wounds after traumas. Importantly, our analyses also show a periodic relapse with the prolonged use of NPWT. However, further studies are needed with a larger, standardized population to confirm these findings

Aim. Infections in long bones can be divided in osteitis, osteomyelitis and septic non-unions. All are challenging situations for the orthopaedic surgeon. Treatment is a mix with debridement, radical resection of infected tissue, void filling with different types of products, and antibiotic therapy of different kinds. In cavitary bone defects, bioglasses such as BAG-S53P4 have given good results in early or mid-term follow-up. Results of such treatment in segmental bone defects remain unknown. The goal of our study was to evaluate efficacity of active bioglass BAG-S53P4 in septic segmental bone defects. Method. A retrospective cohort study has been done in a single specific orthopaedic center devoted to treatment of infected bony situations. All cases were a severe septic bone defect. We have compared the segmental bone defects to the cavitary ones. Results were analyzed on recurrence of infection, bone healing, functional result and complication rate. Results. 14 patients were included with a minimum follow-up of 1 year after treatment. 8 were in the group “cavitary”, 6 in the group “segmental”. The mean age was 54 years-old (30–76). Sex-ratio was 2.5. All patients have been treated with bone resection and debridement of infected bone and tissue, even if more than 1 surgery was necessary in some cases. After cleaning, 7 patients have needed a local flap, and 1 a free flap. Then, all bone defects were filled up by bioglass BAG-S53P4*. Additional antibiotherapy with specific molecules based of the results of bacterial analysis, was given for a minimum time-period of 6 weeks. In the “cavitary” group, the mean volume of BAG-S53P4 was de 21.25 ml (10–60). In the “segmental” group, it was of 12.5 ml (10–20). The healing rate was of 80% in the “cavitary” group and of 100% in the “segmental” one. No complication related to the bioglass insertion was noted. Conclusions. Different publications have been made using bioglass in the treatment of infected bone with a continuous bone such as osteitis or osteomyelitis. Our study is the first one to compare specifically the results obtained in a cavitary defect where the bone is still in continuity, and in a segmental defect. Active bioglass such as the BAG-S53P4 seems to be a good option in the treatment of segmental septic bone defects in the limb. *BonAlive Biomaterials Ltd, Turku, Finland

Aim. Periprosthetic joint infections are a devastating complication after modular endoprosthetic reconstruction following resection of a musculoskeletal tumour. Due to long operating times, soft tissue dissection and immunosuppression, the infection rate after limb salvage is high and ranges between 8% and 15%. The aim of this retrospective single centre study was to assess the reinfection and re-reinfection rate after septic complications of megaprostheses. Method. In this retrospective study, 627 patients with a primary replacement of a musculoskeletal tumour of the lower limb and reconstruction by a megaprosthesis were recorded from 1983 – 2016. 83 out of 621 patients available for follow-up experienced an infection (13.4%). Two patients were treated with debridement and removal of the mobile parts, 61 patients with a one-stage revision, 16 patients with a two-stage revision, and 4 patients with an amputation. The mean follow up was 133 months (range: 2 – 423 months). Results. The reinfection rates after debridement, one-stage revision, two-stage revision, and amputation were 100% (CI 95%: 20 −100%), 49% (CI 95%: 36 – 62%), 38% (CI 95%: 6 – 76%), and 0%, respectively. A reinfection occurred after a mean of 38,7 months (range: 0 to 201 months). The most commonly isolated microorganisms were coagulase negative Staphylococci, followed by Staphylococcus aureus. A re-reinfection occurred in 100% after debridement, in 44% (CI 95%: 22 – 69%) after one-stage revision, in 55% (CI 95%: 31 – 91%) after two-stage revision, and 0% after amputation. Regarding two-stage revision, there was a statistically significant difference in infection rates between patients treated with complete removal of the megaprosthesis and patients with at least one retained component (Fisher's exact test, p = 0.027). Conclusions. Septic failures after megaprosthesis reconstruction of a musculoskeletal tumour of the lower limb are difficult to treat and show high reinfection and re-reinfection rates. A two-stage revision with removal of all components showed the best results among limb salvage procedures for periprosthetic megaprosthesis infection

Septic complications of long bone fracture are still a significant clinical problem. Although inflammatory process after intramedullary nailing is a rare complication, its treatment is complex. The aim of this study is to analyze the effectiveness of the treatment of septic complications of the long bone union with use of Reamer–Irrigator–Aspirator (RIA) technique and intramedullary antibiotic-coated PMMA nailing. An analysis of the effectiveness of treatment of 49 patients with septic non-union of long bones (12 femur, 37 tibia), in which the RIA method was applied with antibiotic cement impregnated intramedullary nailing. Treatment consisted of reaming of long bone canal using the RIA technique and the intramedullary cement coated nail with the targeted antibiotic. Treatment required second stage with nail exchange and PMMA removal after 6 weeks to prevent the resitant strains selection. In a group of patients treated with use of above-mentioned method the remission of inflammatory process was achieved in all cases. 32 (67%) patients developed bone union, 24 patients with tibial and 8 patients with femoral septic bone union disorders. The average duration of bone union obtainment with intramedullary nailing was 37 weeks. The most common inconveniences that occurred during treatment was prolonged wound discharge and pain. Inflammatory complications of fractures in our material involved extensive injuries, usually high-energetic. Stabilization with intramedullary locked nail coated with antibiotic cement after debridement with RIA method is a convincing treatment. An essential element of biological bone union is to provide a good cover of the bone tissue with a soft tissue envelope and sequestrectomy. The success of the treatment of infected pseudoarthrosis may be obtained under condition of: radical removal of inflammation tissue, convincing biomechanical dynamized stabilization and antibiotic therapy

The use of new megaprosthesis for massive bone loss is an option for the replacement of skeletal segments. There are several clinical scenarios that can be associated with this situation including severe trauma with multiple failed osteosynthesis with a non union or with a previous prosthetic replacement of a neighbouring joint; multiple revision of arthroplasty with or without infections or large resections of tumours. The aim of this work is to evaluate retrospectively both clinical and radiological outcomes and any complications in patients treated with megaprosthesis in SEPTIC BONE DEFECTS in our Hospital from February 2012 to January 2015. From February 2012 to January 2014 a total of 20 patients were treated with mono-and bi-articular megaprosthesis subdivided as follows: 4 proximal femur, 11 distal femur, 3 total femur, 1 total humerus and 1 proximal humerus. Clinical and serial radiographic evaluations were performed at 6 weeks, 3, 6, 12, 18 and 24 months. Blood parameters with CRP and ESR were monitored for at least 2 months. The mean follow-up of patients was about 24.4 months (range 5 months to 31 months). The mean age of the patients was 53 years (range 37–80years). Of the patients 20, 9 were female and 11 were male. The aetiology was: 11 septic non unions, 3 infected TKA, 4 infected THR and 2 infected tumor prostheses. We have evaluated retrospectively both clinical and radiological outcomes of 20 patients. They had large bone defects that threatened the viability of the limb. They were treated with megaprosthesis. Although the mean length of follow-up was only 24.4 months they showed encouraging clinical results, with good articulation of the segments, no somato-sensory or motor deficit and acceptable functional recovery. There were three cases of dislocation, one case with rifampicin toxicity, one case with acute prosthetic infection (case that needed debridement and one case with chronic oral antimicrobial. Megaprosthesis provides a valuable opportunity to restore functionality to patients with highly disabling diseases. The number of complications is not depreciable

Knee arthrodesis is a potencial salvage procedure for limb preservation in patients with multiple failures of Total Knee Arthroplasty (TKA) with massive bone loss and extensor mechanism deficiency. The purpose of the study is to evaluate the outcome of bridging knee arthrodesis using a modular and non cemented intramedullary nail in patients with septic failure Total Knee Arthroplasty. Between 2005 and 2013 (9 years), 15 patients (13 female and 2 male) with mean age 71.1 years (range 41 to 85) were treated at our Institution with septic two- stage knee arthrodesis using a modular and non- cemented intramedullary nail after multiple failures of septic Total Knee Arthroplasty. Mean follow- up was 70.1 months (24 to 108 months) with a minimum follow- up of 24 months. We evaluated the erradication of infection clinically and with normalization of laboratory parameters (ESR and CRP), limb length discrepancies and complications (periimplant fractures, amputation rates, wound healing disturbances) and the subjective evaluation of the patients after knee arthrodesis. We reported 11 cases of resolution of the infection (73.3 %), with good tolerance of the implant and a mean limb length discrepancies of 15 mm. Of these, 8 patients had been monitored over 5 years without recurrence of the infection. The mean number of previous operations was 4.9 (range 2 to 9). Two patients (13.3 %) required multiples surgical debridements for uncontrolled sepsis and finally underwent knee amputation. Coagulase- negative Staphylococci (SCN) were the most commom pathogen (53.3 %) followed by polimicrobian infections (26.7 %). One patient continues suppressive antibiotic treatment and 1 patient was treated with a one- stage custom- made arthrodesis nail exchange. Bridging knee arthrodesis using a modular and non- cemented intramedullary nail is a salvage procedure with acceptable results in terms of erradication of infection after septic faliure Total Knee Arthroplasty with restoration of limb length discrepancy. Despite these satisfactory results it is not without serious complications such as knee amputation

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

Introduction. Septic knee arthritis with severe osteoarthritis (OA) presents challenging clinical situations because of unexpected and long time for treatment and less satisfactory clinical outcomes. Septic arthritis with damage to articular cartilage developed osteomyelitis (OM) frequently. Although arthroscopic debridement was the common treatment of septic arthritis, there was some limitation on the management of infected bone structures and then open arthrotomy should be reserved. In the patients of OM located only periarticular areas, the author used the PROSTALAC system for infected total knee arthroplasty (TKA) and achieved good results. Objectives. In periarticular OM with septic knee arthritis in patients with severe OA, we report the rate of control of infection using the PROSTALAC articulating spacer and to assess the clinical outcome after staged TKA. Methods. This study was conducted on a total of 11 patients (11 knees) treated for septic knee arthritis in patients with Kellgren-Lawrence classification grade 3–4 OA between April, 2014 and April, 2015. Of these, we retrospectively reviewed 6 knees of 6 patients (54.5%) who underwent staged TKA using the PROSTALAC articulating spacer. The inclusion criteria were periarticular OM confirmed by magnetic resonance imaging (MRI) and whole body bone scan (WBBS), affected bone could be resected and covered by the PROSTALAC system. There were 2 males and 4 females with a mean age of 64 years (range, 61 to 68 years). Prior to the initial surgery, the average erythrocyte sedimentation rate (ESR) 87mm/h, and C-reactive protein (CRP) 8.8 mg/dl. The mean follow-up period was 14 months (range, 12 to 24 months). For clinical assessment, WOMAC, UCLA, Patient Satisfaction scores and postoperative complications were evaluated. For radiological assessment, weight-bearing radiographs of the knee were obtained to evaluate bone change, component loosening, and recurrence of infection. Results. The mean interval between initial operation using the PROSTALAC system and staged TKA was 8.2 weeks (range, 8–10 weeks). The species could be identified in the culture of aspiration of joint fluid prior to the initial operation. The most frequently found etiologic agent was gram-positive cocci (66.6%), followed by MRSA (16.7%) and yeast like fungi (16.7%). At last review, ESR and CRP returned to normal and follow-up cultures were negative in all patients. We observed improvements in mean WOMAC, UCLA, and Patient Satisfaction scores at last review. Radiographs at final follow-up showed well-fixed implants with no radiographic evidence of loosening or infection. Conclusions. In this study, we observed a 100% microbiologic cure and 89% clinical cure in patients who underwent a staged TKA using the PROSTALAC system with a 14-months follow-up. This method appears to have several important advantages (1) there is less possibility of additional bone resection due to uncontrolled infection of adjacent bone; (2) there are possibly expected interval between two stages and more good patient satisfaction. The staged TKA using the PROSTALAC spacer would have a predictable, favorable effect on the control of infection and improvements in the functional outcomes for the treatment periarticular OM with septic knee arthritis in patients with severe arthritis

Aim. The optimal surgical approach for patients hospitalized for moderate to severe septic bursitis is not known, and there have been no randomized trials of a one-stage compared with a two-stage (i.e., bursectomy, followed by closure in a second procedure) approach. Thus, we performed a prospective, non-blinded, randomized study of adult patients hospitalized for an open bursectomy. Method. Patients were randomized 1:1 to a one-stage vs. a two-stage surgical approach. All patients received postsurgical oral antibiotic therapy for 7 days. These are the final results of the prospective study registered at ClinicalTrials (NCT01406652). Results. Among 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was one-stage in 79 and two-stage in 85. The two groups were balanced with regards to sex, age, causative pathogens, levels of serum inflammatory markers, co-morbidities, and cause of bursitis. Overall, there were 22 treatment failures: 8/79 (10%) in the one-stage arm and 14/85 (16%) in the two-stage arm (Pearson-χ2-test; p=0.23). Recurrent infection was caused by the same pathogen a total of 7 patients (4%), and by a different pathogen in 5 episodes (3%). The incidence of infection recurrence was not significantly different between those in the one- vs. two-stage arms (6/79 vs. 8/85; χ2-test: p=0.68). In contrast, outcomes were better in the one- vs. two-stage arm for wound dehiscence (2/79[3%] vs. 10/85[12%]; p=0.02), median length of hospital stay (4.5 vs. 6 days), nurses’ workload (605 vs. 1055 points) and total costs (6,881 vs. 11,178 Swiss francs) (all p<0.01). Conclusions. For adult patients with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with 7 days of systemic antibiotic therapy, was safe, resource-saving and effective. Using a two-stage approach did not reduce the risk of infectious recurrence, and may be associated with a higher rate of wound dehiscence than the one-stage approach

Introduction. In orthopaedics one of the most common complications is infection. The occurrence of a postoperative infection significantly increases the failure rate; both in the case of prosthetic and trauma surgery. Some patients despite a meticulous antiseptic procedures, a close monitoring of controls peri- and post-operative undergo the development of infection of the fixation devices with the risk of developing osteomyelitis. This risk is highly increased in the distal leg because of the known problems with blood supply and poor muscle coverage. The functionality of the affected segment is impaired, quoad fuctionem, with increased risk of amputation and sometimes with poor prognosis, quoad vitam. The therapeutic strategy proposed by our group is to treat an osteomyelitic site as a pseudo-tumor with a megaimplant following a ladder strategy driven by the NUSS classification. This work shows our experience with a developing system by Waldemar-LINK highlighting critical issues and preliminary results. Objectives. The purpose of this study is to evaluate retrospectively the early outcome after the implantation of this megaprosthesis of the lower leg in infected post-traumatic bone defects and septic peri-device bone loss. We registered all the complications and infection recurrence. Methods. Between January 2013 today we have developed this system following the chamber induction technique (C.I.T.). We perform a 2 steps procedure: 1° step: resection, debridement, devices removal and bi-antibiotic spacer implantation; 2° step: spacer removal and megaprosthesis implantation. Results. Our first 10 patients with lower leg septic critical size bone defect were post-traumatic, 3 have ended the C.I.T. procedure with good clinical result and return to function. Conclusions. The background experience in orthopaedic oncology, has allowed to develop megaimplants to break the vicious cycle of osteomyelitis and restore an optimal performance of the affected segment. We can perform a one step procedure only when all the infected segment is entirely removed, in other partial resections is better to follow a two steps procedure. In the development of this project will be possible to connect to a Megasystem C; this system will then be able to replace from the hip to the foot in the most complex cases. We also concluded that this type of complex surgery must be performed in specialized centers where knowledge and technologies are present