Aim. Bone and implant-associated infections caused by microorganisms that grow in biofilm are difficult to treat because of persistence and recurrence. Systemic administration of antibiotics is often inefficient because the poor vascularization of the site of infection. This issue has led to the development of biomaterials capable to locally deliver high doses of therapeutic agents to the injured bone with minimal systemic effects. In this context, calcium sulphate/hydroxyapatite (CS/HA) bone graft substitutes are widely used being safe, osteoconductive and resorbable biomaterials that can be easily enriched with consistent amounts of antibiotics. In this in vitro study, the capability of the eluted antibiotics to select the tested bacterial strains for antibiotic resistance was evaluated to confirm the safe use of the product. Method. S. aureus, S. epidermidis and P. aeruginosa isolated in our Institute from bone and joint infection with different resistance phenotypes were used. 6 × 2.5 mm CS/HA discs were generated by pouring the antibiotic loaded formulations in a mold and were used as a modified disk diffusion test. The resistance selection was evaluated by subculturing cells growing on the edge of the zone of inhibition (ZOI) for seven days. Minimum inhibitory concentrations (MICs) of gentamicin and vancomycin were determined by broth microdilution method before and after the selection of resistance assay. In addition, MICs were assessed after seven day passage on antibiotic free agar plates to evaluate if eventual decrease of antibiotic susceptibility was stable or only transient. Results. Commonly, no adaptation in presence of both CS/HA formulations was observed by analysing ZOI on agar medium. The kinetic of decrease of the ZOI was similar between the strains, with the exception of gentamicin resistant staphylococci in presence of gentamicin loaded CS/HA, which was faster with respect to the susceptible strains. Conclusions. The present study shows that elution of gentamicin and vancomycin from CS/HA bone graft substitutes did not induce a decrease in susceptibility to these antibiotics in an in vitro setting, suggesting the safe use of the product

Periprosthetic joint infection (PJI) in geriatric and/or multimorbid patients is an enormous challenge for orthopaedic surgeons. Revision procedures have also been demonstrated to expose patients to higher infection risks. Prior patient stratification according to presumed infection risks, followed by a more potent local antibiotic prophylaxis protocol with selective use of DALBC, is an interesting strategy to decrease the burden of PJI in high risk patients. The PubMed & EMBASE databases were screened for publications pertaining to the utilization of DALBC in cement for infection prophylaxis & prosthesis fixation. 6 preclinical & 7 clinical studies were identified which met the inclusion criteria and were stratified by level of clinical evidence. Only those studies were considered which compared the PJI outcome in the DALBC vs the SALBC group. (1). DALBC have been shown to exert a much stronger and longer lasting inhibition of biofilm formation on many PJI relevant bacteria (gram-positive and gram-negative pathogens) than single gentamicin-only containing cements. (2). DALBC use (COPAL G+C) in the intervention arm of 7 clinical studies has led to a significant reduction of PJI cases in a) cemented hemiarthroplasty procedures (3 studies, evidence level I and III), in b) cemented septic revision surgeries (2 studies, evidence level III), in c) cemented aseptic knee revisions (1 study, evidence level III) and in d) cemented primary arthroplasties in multi-morbid patients (1 study, evidence level III-IV). These benefits were not associated with more systemic side effects or a higher prevalence of broad antimicrobial resistancies. Use of DALBC is likely to be more effective in preventing PJI in high risk patients. The preliminar findings so far may encourage clinicians to consolidate this hypothesis on a wider clinical range

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures. A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections. Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance. Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics. This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study

Trauma, including major Orthopaedic Surgery, results in an immuno-inflammatory response which is variable in systemic effects.This response is patient specific. The systemic effects may be exaggerated and cause distal organ damage. This study assesses the effects of elective hip and knee arthroplasty on liver function tests. A prospective study of liver function in 316 patients (168 males and 148 females) undergoing elective total hip and knee joint replacement was undertaken by one surgeon using standardised anaesthetic, surgical and post-operative protocols. Alanine aminotransferase (ALT), Aspartate transaminase (AST), Alkaline phosphatase (ALP) and Gammaglutamyl transpeptidase (GGT) were assessed pre-operatively and at one day, one week and six weeks following surgery. There were 166 hip and 150 knee replacement patients. Of the hip replacements, 35% were cemented, 35% hybrid and 30% cementless. All knee replacements were cemented:. ALT levels (IU) pre-operatively were 20, one day 17, one week 45.5 and at six weeks 17. AST levels (IU) pre-operatively were 21, one day 22, one week 38 and at six weeks 19. ALP levels (IU) pre-operatively were 77, one day 57, one week 88.5 and at six weeks 90. GGT levels (IU) pre-operatively were 24, one day18, one week 68 and at six weeks 29. For all enzymes there was a highly significant (p < 0.001) increase in values at one week. ALT and AST levels had returned to normal and GGT nearly normal at six weeks. ALP, also a bone enzyme, remained elevated at six weeks. There was no significant difference for age or gender. There was no significant difference for cemented, hybrid or cementless hips. Liver function tests become elevated one week following elective joint replacement. This is not related to cement. The cause is probably multifactorial and major likely contributory factors are patients' immuno-inflammatory response and drug effects. Surgeons should be aware of this phenomenon and undertake pre-operative LFT screening routinely

Fretting corrosion of taper junctions is long known and of great concern, because of metal ion and particle release and their related adverse local and systemic effects on the human body (1–3). Orthopedic taper junctions are often comprised of CoCr29Mo6/TiAl6V4 pairings. Beside others the imprinting of the TiAlV-machining marks into the CoCrMo-taper is of clinical interest (4, 5). Thus, the multifactorial details and their interdependencies on the macro-, micro, and nanoscale are still a matter of research (6). This contribution presents the mechanisms of imprinting found in an in-vitro fretting corrosion test. The worn surfaces, the lubricant as well as its remains were analyzed after test and the findings brought into relation to the characteristic wear sub-mechanisms. The fretting tests were conducted by means of a cylinder-on-pin set-up. All details about the test and the sequence of analyses can be found in (7, 8). A marked tribofilm of C-rich organic matter and oxidized wear particles of both bodies was generated at the TiAlV/CoCrMo contact area (Figure 1a, c). After removing the tribofilm chemically, extremely fine scratches of sub-µm depth became visible on the CoCrMo body (Figure 1b). The TiAlV body showed shallow shelves leaving troughs filled with grainy debris (Figure 1d) mainly of Ti-oxide wear particles. The shelves stick to the surfaces and, therefore, move relatively to the counterbody. In combination with the grainy debris this brings about “Microploughing” on the CoCrMo surfaces. Microploughing is known for destroying any passive film resulting in “Tribocorrosion”. The question remains how the shelves are formed. From the surface analyses one could conclude that they point towards “Delamination”. But this would also mean that they would not stick rigidly to the surfaces but be ejected from the contact area. Focused Ion Beam (FIB) cuts were done in order to investigate the near- and subsurface structure of the shelves in order to clarify the governing mechanisms (Figure 2). Below the platinum protection layer appears a laminated structure of highly deformed nanocrystalline and amorphous areas. EDS confirmed that the lighter intermediate layers consist mainly of Ti-oxide. This microstructure is supposedly formed by severe plastic deformation and the generation of shear bands, which under fretting pile up on top of each other. This cannot be connected to “Delamination”. We therefore propose to categorize the formation mechanism of these shelves as a specific form of microploughing. Thus, imprinting is neither driven by any galvanic effects (9) nor by hardness differences of TiO. 2. and Cr. 2. O. 3. (10) but by microploughing on the TiAlV-body leading to tribocorrosion at specific sites of CoCrMo what imprints the surface grooves of the softer TiAlV into the harder CoCrMo. For any figures or tables, please contact the authors directly

Introduction. Today, Uganda has the second highest rate of road accidents in Africa and the world after Ethiopia. According to the World Health Organization's Global Status Report on Road Safety 2013, Uganda is named among countries with alarmingly high road accident rates. If such trend of traffic accidents continues to increase, the health losses from traffic injuries may be ranked as the second to HIV/AIDS by 2020. These road traffic accidents often result in terrible open injuries. Open fractures are complex injuries of bone and soft tissue. They are orthopedic emergencies due to risk of infection secondary to contamination and compromised soft tissues and sometimes vascular supply and associated healing problems. Any wound occurring on the same limb should be suspected as result of open fracture until proven otherwise. The principles of management of open fracture are initial evaluation and exclusion of life threatening injuries, prevention of infection, healing of fracture and restoration of function to injured extremity. Because of the poor hygienic circumstances and the high rate of cross-infection due to the crowded patient-wards, the risk of getting a post-operative infection is relatively high. Osteoset-T® (Wright Medical) is a medical grade calcium sulfate bone graft substitute which is enhanced for use in infected sites by incorporating 4% tobramycin sulfate. The tobramycin is released locally, allowing therapeutic antibiotic levels at the graft site, while maintaining low systemic antibiotic levels. This local treatment of infection allows new bone formation in the defect site, while decreasing potential systemic effects. Purpose/aim. Prevention and treatment of postoperative osteomyelitis by introducing alcoholic hand-sanitizers and the use of wound debridement and implantation of a medicated bone graft substitute. Materials and Methods. We treated some existing osteomyelitis cases and some open fractures with the medicated bone graft substitutes, at Kilembe Mines Hospital, Uganda. A proper debridement with sequestrectomy when needed was performed after which the pellets were implanted and the wound was closed. A preoperative X-ray was taken as well as clinical pictures. Post-operative x-rays were obtained at 6 weeks post-operative and 6 months post-operative when possible. The case presented in this abstract is a 25year old nurse with a bilateral open tibia fracture due to a motorcycle accident. A proper debridement and plate and screw osteosynthesis was performed after which the pellets were implanted underneath the plate. After surgery systemic antibiotics were given and the wound-dressings were changed when dirty. Results. The case presented is currently 6 months post-operatively and is able to walk without support. The fracture is fully consolidated and the wounds are healed without any sign of infection. Conclusion. Even though the clinical follow-up is not easy in this developing country setting, we were able to evaluate some patients postoperatively. By introducing better hand hygiene (by use of alcoholic hand sanitizers) and medicated bone graft substitutes, we hope to be able to prevent osteomyelitis after open fractures and also to treat chronic osteomyelitis cases. More people are being treated at the moment and a case-control study will be started soon

Previous authors have suggested that the analgesic effects of intra-articular morphine may be beneficial. Clonidine has been found to potentiate the analgesic effect of morphine. Following knee arthroscopy, morphine has demonstrated equivocal effect in comparison to bupivicaine for analgesia while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine following hip arthroscopy. The purpose of this study was to evaluate the efficacy of intra-articular morphine in combination with clonidine on pain and narcotic consumption following hip arthroscopy surgery for femoroacetabular impingement. A retrospective review was performed on 43 patients that underwent hip arthroscopy between September 2014 and May 2015 at our institution for femoroacetabular impingement. All patients received preoperative Celebrex and Tylenol per our anesthesia protocol, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 mcg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the two groups. We found that patients who received intra-articular morphine and clonidine used significantly less opioid analgesic in the PACU, with 23 mEq of morphine equivalents required in the intra-articular morphine and clonidine group compared to 40 mEq of opiod equivalents in the non-injection group (p=0.0259). There were no statistically significant differences in time spent in recovery prior to discharge or in VAS pain scores recorded immediately post-operatively and at one hour following surgery. In conclusion, we found that an intraoperative intra-articular injection of morphine and clonidine significantly reduced the amount of narcotic requirement following hip arthroscopy. We do believe that there may be significant benefits to this, including less systemic effects from overall narcotic usage in the perioperative period. Our study demonstrated a beneficial effect of intra-articular morphine that may help with overall pain improvement, less narcotic consumption, and improved patient satisfaction following outpatient hip arthroscopy. This study provides the foundation for future research currently being conducted in a randomised-control setting

Evaluation of the effectiveness of biodegradable bone substitute with high doses of antibiotics in cavitary osteomyelitis and infected nonunions. The authors evaluated 8 cases, 5 of them related to osteomyelitis with bone sequestration and other 3 regarding infected nonunions. All of them had in common the persistence of infection after antibiotic therapy. All infections were confirmed by microbiological studies. In all cases the surgeons conducted a thorough surgical debridement and filling of bone defects with Herafill®. Later a tight clinical, analytical and imagiological control was performed. Five of the cases were a success with simultaneous healing of the bone loss and treatment of the infection. These corresponded to the cases of cavitary osteomyelitis. In the remaining 3 cases, despite infection eradication, union was not achieved and additional surgical procedures were required for definitive treatment of nonunion. In the treatment of bone infection, use of high doses of antibiotics at the site is a consensus as it allows eradication of the infection with lower systemic effects. With the emergence of biodegradable bone substitutes, the need for a new surgical intervention for their removal can be avoided. Properties of calcium sulfate and calcium carbonate stimulate osteogenesis at the site, allowing their absorption and replacement by bone matrix. These properties make them ideal to usage in cases of cavitary bone defects. Our experience supports the idea that the use of high doses of antibiotics locally permits remission of the infection. However, when this is implemented through a bone substitute, it is possible to achieve osteogenesis in bony cavities. Nevertheless, when applied to infected nonunions, their role seems to be limited to the eradication of the infection

Metal-on-metal bearing surfaces were used frequently until recently because of the potential for decreased wear and the ability to use large femoral heads which can reduce instability. However, data reported in the Australian registry over the past 5 years demonstrated an increase in failure rates compared to metal-on-polyethylene bearings. In addition, adverse local tissue reactions (ALTR) associated with pseudotumors and destruction of the soft tissue around the joint have led to revision of these implants. Unfortunately, at the present time there is no optimal management strategy that has been delineated for metal-on-metal implants because of a lack of evidence. The biologic response to metal-on-metal implants is usually local but may be systemic. The management of these patients is complex because patients may have pseudotumors and/or elevated metal ion levels and be asymptomatic. In addition, there are a number of intrinsic causes (loosening, infection, iliopsoas tendinitis) and extrinsic causes (spinal disease, trochanteric bursitis) that can be a source of pain. There is no evidenced based approach to manage these patients and no single test should be used to determine treatment. A thorough clinical evaluation is essential and blood tests are necessary to rule out infection. Imaging studies including plain radiographs and a MARS MRI are needed to evaluate either the stability of the prosthesis and to assess for the presence of pseudotumors and soft tissue destruction around the implant. Patients with symptomatic hips and evidence of muscle involvement on MRI require revision. Finally, the clinician must always be aware of the potential for systemic effects which require early and aggressive intervention to limit the adverse response to the metal and the metal bearing

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

Introduction. Wear plays a key role in the clinical outcome of total hip replacements (THR). In addition, increased frictional moment can stress the implant interfaces which may lead to high torsional loadings in the intermodular taper junction (fretting) and cup loosening and to the development of noise (squeaking). Against the background of larger head diameters (increased range of motion and decreased risk of dislocation), the friction induced by the joint articulation is of particular interest. As of now, the investigation of friction with the use of relevant joint kinematics and loadings are limited to numerical studies. Experimental approaches use simplified models which do not take into consideration complex activities. Thus, with the aim of this study is the identification of articular frictional moments that consider critical in vivo loading conditions and kinematics as well as the clinical cup inclination, head size and clearance of ceramic-on-ceramic hip bearings. Materials and Methods. A standard hip simulator (Minibionix 852 with 4 DOF Hip setup, MTS, Eden Prairie, USA) was modified in order to allow for high-precision friction measurements during head-insert articulation in all 6 DOF (MC2.5D-500, AMTI, Boston, USA). Disturbing systemic effects have been minimized by using quasi frictionless aerostatic lateral force compensation (Eitzenberger, Wessobrunn, Germany) and cross talk compensation. Beside the standard protocoll for in vitro wear assessment (ISO 14242-1), more complex profiles from in vivo patient data (Heidelberg Motion Lab and Orthoload database) have been used: normal walking with different walking speeds and patient's weights, stairs up/down and start-stop conditions. All-ceramic bearings (Biolox delta, Ceramtec, Plochingen, Germany) have been orientated in clinically relevant cup inclinations (30, 45, 60 and 75 deg). For each head diameter (28, 36 and 48 mm) n=8 specimens have been devided in two groups: small and large clearance according to the manufacturer's specification. All tests were run at 37°C in diluted bovine serum (20 g/l protein content). Results and Discussion. For all continuously running activities (normal walking, stairs up/down and ISO standard), increased resulting frictional moments have been measured with larger head diameters and smaller clearances in a range of less than 6 Nm. This data corresponds well to the results of a well-lubricated ceramic-on-ceramic bearing from numerical studies. In addition, the initial breakaway torque after a short resting period (start-stop initiation) was increased, where the highest maximal moments have been measured with increasing resting durations and larger head diameters (large clearance: up to 11 Nm, small clearance: up to 20 Nm). Interestingly enough, not in all cases a negative effect on the resulting moment was seen with increasing cup inclination, even though no subluxation was induced. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Metal on metal bearing surfaces were used frequently until recently because of the potential for decreased wear and the ability to use large femoral heads which can reduce instability. However, data reported in the Australian registry over the past 5 years demonstrated an increase in failure rates compared to metal on polyethylene bearings. In addition, adverse local tissue reactions (ALTR) associated with pseudotumors and destruction of the soft tissue around the joint have led to revision of these implants. Unfortunately, at the present time there is no optimal management strategy that has been delineated for metal on metal implants because of a lack of evidence. The biologic response to metal on metal implants is usually local but may be systemic. The management of these patients is complex because patients may have pseudotumors and/or elevated metal ion levels and be asymptomatic. In addition, there are a number of intrinsic causes (loosening, infection, iliopsoas tendinitis) and extrinsic causes (spinal disease, trochanteric bursitis) that can be a source of pain. There is no evidence based approach to manage these patients and no single test should be used to determine treatment. A thorough clinical evaluation is essential and blood tests are necessary to rule out infection. Imaging studies including plain radiographs and a MARs MRI are needed to evaluate either the stability of the prosthesis and to assess for the presence of pseudotumors and soft tissue destruction around the implant. Patients with symptomatic hips and evidence of muscle involvement on MRI require revision. Finally, the clinician must always be aware of the potential for systemic effects which require early and aggressive intervention to limit the adverse response to the metal and the metal bearing

Bone metastases are the most common cause of cancer-related pain and often lead to other complications such as pathological fractures and spinal cord compression. Bisphosphonates (BP) are a class of potent anti-resorptive agents commonly prescribed to retard osteoporosis progression. Interestingly, BP may have indirect anti-tumour properties through negative effects on macrophages, osteoclasts, endothelial cells and their ability to suppress matrix metalloproteinase (MMP) activity. Currently, the use of bisphosphonates for cancer therapy is generally restricted to high dose systemic delivery. The purpose of this study was to investigate the effects of direct local delivery of Zoledronate at the metastatic site in a mouse model of breast cancer metastasis to bone. Seven days following intra-tibial inoculation with MDA-MB-231 (N = 1× 105) breast cancer cells in athymic mice, the experimental group (N = 11) was treated by direct infusion of 2µg of Zoledronate into the tibial lesion (three times/week for three weeks) and compared to vehicle-treated mice (N = 5). The formation of bone metastases and growth of the lesions were followed up by weekly bioluminescence imaging. In a subsequent experiment, a comparison of the effects of local versus systemic delivery of Zoledronate on the formation of osteolytic bone metastases was carried in athymic mice (N = 15). Seven days following intra-tibial inoculation with MDA-MB-231 breast cancer cells, the systemic group (N = 5) was treated with Zoledronate (0.025mg/kg) once per week for four weeks and compared to systemic delivery of vehicle (N = 4). Following treatment, the mice were sacrificed, and micro-CT images of the right tibia were obtained. Bone volume to tissue volume ratio (BV/TV%) was determined using µ-CT biomarkers. The first experiment showed a statistically significant increase in mean bone volume/tissue volume ratio% (BV/TV%) in the treated group (7.0±1.54%) as compared to the control group (3.8±0.48%) (P <0.001, 95%CI=1.9–4.3). This corresponded to a net increase of 84.21% in response to Zoledronate treatment. Comparison between the local and systemic effects of Zoledronate also revealed a significant increase in the BV/TV% in the locally treated group (6.69±0.62%) when compared to the cohort administered systemic bisphosphonate treatment (4.03±0.44%) (P<0.001, 95%CI=1.24–3.20), corresponding to a net increase of 66.0%. These preliminary results suggest that high dose sustained release of Zoledronate can lead to a significant inhibition of tumor-induced osteolysis. Moreover, comparison between local and systemic delivery revealed that the effect of local bisphosphonate administration exceeds the benefits of systemic delivery in terms of osteolysis inhibition. Lastly, the noted effects of Zoledronate local delivery triggers the need for further assessment of its anti-tumour activity

Introduction:. Open bone graft harvesting continues to be recognized as the gold standard of obtaining autograft in patients needing bone graft. Conventional bone graft harvesting using the iliac crest is often cited as having significant donor site morbidity and complications. Intramedullary harvesting, using a reamer irrigation aspiration system (RIA) has recently become available. Method:. We performed a retrospective case series on 16 patients, where this system was used. A single pass reaming technique to harvest autograft from the femoral canal was performed. Fluoroscopy was used to size the canal and to confirm placement of a guide wire. Bone harvest volumes, complications encountered and donor site satisfaction post operatively was assessed. Patient satisfaction was determined via telephonic interviews at regular intervals with follow-up times up to 2 years. Results:. The study group consisted of 16 patients with an average age of 31 years. The mean post-operative follow up period was 18.8 months. The average amount of bone harvested was 39.6 cc. Although two technical complications were encountered intra-operatively, there were no systemic effects due to reaming. Most of the patients reported mild to severe pain immediately post operatively with an average pain score of 6.5 (1–10). Only seven patients reported minor pain at the donor site with the last interview bringing the average pain score down to 1.2. All pain scores reduced to zero after 21 months. Conclusion:. RIA was found to be a safe technique with reliable volumes of autograft obtained. Patients recovered quickly with no wound complications reported and minimal donor site morbidity at early follow-up. This new technique seems to be a viable option as an alternative to conventional bone graft harvesting

The cause of elbow tendinosis is most likely a combination of mechanical overloading and abnormal microvascular responses. Numerous methods of treatment have been advocated. In this study, we evaluated the use of platelet-rich plasma (PRP) as a treatment for resistant epicondylitis. The rationale for using platelets is that they participate predominantly in the early inflammation phases and degranulation. They constitute a reservoir of critical growth factors and cytokines which when placed directly into the damaged tissue, may govern and regulate the tissue healing process. We looked at 25 patients (19 with lateral and 6 with medial) who failed to improve after physiotherapy, cortisone injections and application of epicondylar clasps and assessed the efficacy of platelet-rich plasma injections using Gravitational platelet separation system (GPS). The cohort of patients included over a period of three years had physiotherapy, stretches, epicondylar clasp and an average of 2.9steroid injections (1–6) before having a PRP injection. The mean patient age was 43 years ranging between 24 and 54. There were 11 men and 14 women. The study included 19 patients with lateral epicondylitis and 6 patients with symptoms on the medial side. The ratio between dominant and nondominant side was according to the literature: 76%. The quick DASH scores imroved by 14% on an average in the first 3 months and further 26% in the following 9 months. 4 patients needed reintervention, 3 lateral and 1 medial and had surgical release between 6 and 12 months. 2 of them had reinjections before surgery. No local infections except mild inflammation and no systemic effects were noted. Within the limitations of being a case series and limited follow-up PRP injections provided a safe and progressive benefit over a period of 1 year in refractory cases, providing a good nonoperative alternative

Introduction. Long bone surgery and marrow instrumentation represent significant surgical insults, and may cause severe local and systemic sequelae following both planned and emergent surgery. Preconditioning is a highly conserved evolutionary endogenous protective mechanism, but finding a clinically safe and acceptable method of induction has proven difficult. Glutamine, a known inducer of the heat shock protein (HSP) response, offers pharmacological modulation of injury through clinically acceptable preconditioning. This effect has not been previously demonstrated in an orthopaedic model. Aims. The aim of the study was to test the hypothesis that glutamine preconditioning protects against the local and systemic effects of long bone trauma in a rodent model. Methods. Thirty two adult male Sprague-Dawley rats were randomised into four groups:. Control group which received trauma without preconditioning,. Normal Saline preconditioning 1 hour before trauma,. Glutamine preconditioning 1 hour before trauma, and. Glutamine preconditioning 24 hours prior to trauma. Trauma consisted of bilateral femoral fracture following intramedullary instrumentation. Blood samples were taken just prior to the insult, and at an interval four hours following this. The animals were then sacrificed, bronchioalveolar lavage (BAL) performed and skeletal muscle and lung harvested for evaluation. Results. Glutamine pretreated rats had lower CK levels at 4 hours than those treated with normal saline. Renal dysfunction was less in pre-treated animal, and there was a significant reduction in neutrophil infiltration into BAL fluid. Finally glutamine pre-treated rats showed less muscle and lung oedema. This effect was more pronounced for the group which received glutamine 24 hours before trauma than the group receiving glutamine one hour before trauma. Conclusion. This data suggests that preconditioning with a single bolus of intravenous glutamine prior to planned orthopaedic intervention may afford local and end-organ protection

Introduction & Aims. Intravenous administration of tranexamic acid (TXA) has been shown to be effective in reducing blood loss and transfusion requirements in total knee arthroplasty (TKA). However, concern exists that I.V. TXA may heighten the risk of venous thrombo-embolism. The intra-articular administration of TXA is an attractive and simple option to deliver this agent locally with minimal systemic effects on inducing hypercoagubale states. In this study, we analysed the effect of varying dosages of intra-articular tranexamic acid on blood loss in TKA. Methods. 176 patients who underwent a unilateral TKA for osteoarthritis were retrospectively analysed. Patients were excluded if they underwent a revision knee arthroplasty, concurrent removal of hardware, extensive synovectomy, or lateral patellar retinacular release. All patients underwent a primary cemented posterior stabilised TKA by 2 surgeons using a medial parapatellar approach. Tourniquet was only inflated for initial exposure and intra-articular drains were not used. Patients were separated into three groups; a control group (n=56) who did not receive TXA, and 2 treatment groups who received intra-articular TXA with doses of 1500 mg (n=60) or 3000 mg (n=60). Once the wound was closed, tranexamic acid was injected intra-articularly via an epidural pain catheter. Haemoglobin (Hb) levels were taken pre-operatively and on post-operative days 1 and 2. The primary outcome measure was mean difference in Hb drop between the three groups. Results. There was a statistically significant difference in post-operative Hb drops amongst the three groups. Those who received TXA had a greater reduction in the blood loss compared to the control group. In the control group, the mean haemoglobin pre-operatively was 140.13 g/L with an average drop of 34.30 g/L by post-operative day 2. Patients who received 1500 mg of TXA had a mean haemoglobin of 138.95 g/L pre-operatively with an average drop of 28.67 g/L by post operative day 2. Those who received 3000 mg had a pre-operative haemoglobin of 138.02 g/L with an average drop of 22.73 g/L. There were no differences in post-operative complications or local reactions. All inter-group differences in Hb drop on day 2 were statistically significant (p < 0.001, t tests and ANOVA). Conclusions. There appears to be a dose-dependent effect of intra-articular tranexamic acid on blood loss in TKA, with more efficacy with higher dosages. Intra-articular administration of TXA is an effective and simple way to decrease post-operative blood loss in TKA

Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty. Highly crosslinked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly crosslinked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. The challenge, however, is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly crosslinked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly crosslinked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode. During this same decade metal-on-metal implants had seen a significant resurgence in use. Metal-on-metal implants had in-vitro advantages with very low wear rates. They allowed the use of large metal heads and articulations, thereby improving range of motion and stability. Concerns always existed regarding the production of metal ions and the potential for metal hypersensitivity, as well as possible systemic effects. Metal hypersensitivity remains a diagnosis of exclusion with no definitive diagnostic tests to either screen for it, or diagnose it, if suspected. Over the past few years metal-on-metal implant use has dropped significantly, to the point now in 2013, where the only remaining application is resurfacing implants in the younger male patient. Ceramic-on-ceramic bearings enjoy the lowest wear rates of all currently available hip articulations. Historically there has been concern regarding fracturing of both the inserts and the heads, although current generation ceramic-on-ceramic bearings have a much lower reported fracture rate. The phenomenon of a squeaking articulation remains a concern for both patient and surgeon. Conflicting reports exist on whether this is related to implant malposition or is a function of the bearing itself. As with other bearings, improvements in technology continue to evolve and newer ceramics have recently been introduced and are in clinical practice. The future will continue to see the evolution of the articulation in total hip arthroplasty. Patients are undergoing total hip replacements at younger ages and clearly have higher demands than seen historically. That being said, two factors will have a major influence on future developments. The tremendous clinical success of highly crosslinked polyethylene should have us all question the need for significant changes in bearing material and the current environment following the multiple issues with metal-on-metal is one of evolutionary, rather than revolutionary, design and introduction

Aims

Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier.

Only a little over a decade ago the vast majority of primary total hip replacements performed in North America, and indeed globally, employed a conventional polyethylene insert, either in a modular version or in a cemented application. Beginning in the early 2000's there was an explosion in technology and options available for the bearing choice in total hip arthroplasty. Highly cross-linked polyethylene was introduced in 1998, and within a few short years the vast majority of polyethylene inserts performed in North America were manufactured from this material. Globally there was a mixed picture with variable market penetration. Surgeons had seen historically poor results with attempts at “improving” polyethylene in the past and many were hesitant to use this new technology. Many randomised clinical trials have been performed and all have shown to a greater or lesser degree, that indeed the highly cross-linked polyethylene insert has undergone less linear and volumetric wear than its more conventional counterpart. This replicates well the hip simulator data. The challenge however is as we approached mid-term results, orthopaedic manufacturers began altering the polyethylene to improve wear and improve mechanical strength. Therefore while ten-year and greater data will ultimately be published, the actual polyethylene in use at that time will be a different material. Additionally while wear rates are undoubtedly lower, we are still waiting for long-term results of actual osteolytic lesion development and the effect that highly cross-linked polyethylene will have on this clinical scenario. That being said, with over a decade of clinical experience, unquestionably highly cross-linked polyethylene has truly been a revolution in design, essentially eliminating polyethylene wear as an early failure mode. During this same decade metal-on-metal implants had seen a significant resurgence in use. Most major orthopaedic companies produced a metal-on-metal implant whether in the form of a more conventional modular insert, or a monoblock resurfacing-type implant, or both. Metal-on-metal implants had in-vitro advantages with very low wear rates. They allowed the use of large metal heads and articulations, thereby improving range of motion and stability. Concerns always existed regarding the production of metal ions and the potential for metal hypersensitivity, as well as possible systemic effects. Metal hypersensitivity remains a diagnosis of exclusion with no definitive diagnostic tests to either screen for it, or diagnose it, if suspected. Over the past few years metal-on-metal implant use has dropped significantly, to the point now in 2013, where the only remaining application is resurfacing implants in the younger male patient. Ceramic-on-ceramic bearings enjoy the lowest wear rates of all currently available hip articulations. Historically there has been concern regarding fracturing of both the inserts and the heads, although current generation ceramic-on-ceramic bearings have a much lower reported fracture rate. The phenomenon of a squeaking articulation remains a concern for both patient and surgeon. Conflicting reports exist on whether this is related to implant mal-position or is a function of the bearing itself. As with other bearings, improvements in technology continue to evolve and newer ceramics have recently been introduced and are in clinical practice. The future will continue to see the evolution of the articulation in total hip arthroplasty. Patients are undergoing total hip replacements at younger ages and clearly have higher demands than seen historically. That being said, two factors have will have a major influence on future developments. The tremendous clinical success of highly cross-linked polyethylene should have us all question the need for significant changes in bearing material and the current environment following the multiple issues with metal-on-metal is one of evolutionary, rather than revolutionary, design and introduction