Ultrasound treatment can be used as an alternative to surgical methods for treating non-union or to enhance healing in a delayed union. This study presents our short-term results of using low intensity pulse ultrasound stimulation in long bone non-union. 18 patients with surgically treated long bone non-union were treated using the Exogen® ultrasound stimulator (Smith & Nephew Inc., UK). The average age of patients was 48 years (20–73 yrs). There were 8 femur fractures, 9 tibial fractures and 1 knee arthrodesis. 5 of these patients had infected non-union. The average follow up after initiation of treatment was 4 months (range 2–8 months). They received 20 minutes stimulation daily at the fracture site with regular follow up in clinic. We reviewed their serial radiographs and clinical progress. The mean interval to initiation of the ultrasound treatment was 7.9 months (2–27 months). Complete bony union was obtained in 6 of the 18 cases (33%) within 4 months of initiation of treatment. In 7 of 18 cases (38%) there was good evidence of progress towards bony union, while in 4/18(22%) patients there was no progress towards union at average of 4 months (range 2–8 months). There were no complications noted with this treatment. Most non-unions are treated by surgical revision, with consolidation rates ranging from 85 to 100% according to previous studies. Our study suggested 72% patients showing progress towards union with 33% achieving bony consolidation at 4 months. Patients with infected non-union also benefitted from this treatment. In summary ultrasound treatment can be a viable option to treat long bone non-unions, which may avoid the morbidity and complications associated with surgery.

Fracture related infection, in particular chronic osteomyelitis, requires complex management plans. Meta analyses and systematic reviews have not found a gold standard of treatment for this disease. In 2017 an alternative treatment protocol was undertaken in our institution; whereby staged surgery with the use of cheaply manufactured tailored antibiotic cement rods was used in the treatment of chronic osteomyelitis, secondary to traumatic long bone fractures. Short term outcomes for this protocol demonstrated a 75.7% microbiological resolution to a negative culture and a good clinical outcome of 84.2% overall was demonstrated in terms of sinus resolution, skin changes, pain and function. Our aim now was to assess the long term outcomes of this treatment strategy. A cross-sectional study of patients who had previously undergone the set treatment protocol was performed. Patient satisfaction, effects on activities of daily living, return to work and clinical improvement at 5 years following the intervention were assessed using a patient questionnaire and the validated AAOS lower limb score. The average AAOS lower limb score was 88 which was en par to other similar studies. 80% of patients had returned to some form of work. Ongoing mild pain was a persistent problem for 50% of the patients however 98% of the patients were overall satisfied with the treatment satisfaction at 5 years. Only 1 patient required further treatment. 8 patients could not be located for follow up. Chronic osteomyelitis remains a complex disease to treat. This treatment protocol demonstrates favourable microbiological, serological and clinical short term outcomes and favourable patient satisfaction and functional long term outcomes at 5 years. Our study highlights antibiotic targeted cement rods as a feasible treatment option in managing chronic osteomyelitis

Introduction. This study reports on minimum 2 year follow up outcomes on functional and quality of life of patients after undergoing bilateral osseointegration in comparison to traditional socket prosthesis. Materials & Methods. This is a prospective pilot study of 35 patients, consisting of 30 males and 5 females, aged 22–66 (mean 36) years at surgery, with minimum two-year follow-up. Selection criteria were age over 18 years, bilateral amputees who had socket-related problems or were wheelchair-bound with short stumps and non-reconstructable limb pathology. Principle outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation (Q-TFA), Short Form Health Survey 36 (SF-36), Six Minute Walk Test (6MWT), Timed Up and Go (TUG), and K-levels. Adverse events were recorded including infection, revision surgery, fractures, and implant failures. Results. Comparisons were made using differences between the mean pre-operative and mean post-operative values for each outcome measure. Significant improvements in all validated outcome measures were observed. All patient who were wheelchair bound prior to the surgery were able to mobilise post operatively. The occurrence levels of adverse events, including the infection rate and revision rate within this patient cohort, were similar to other established trans-femoral osseointegration studies. Conclusions. These preliminary results indicate that osseointegration surgery is a safe and effective alternative treatment for bilateral amputees experiencing socket-related discomfort. Compared to the suboptimal outcomes of socket prostheses, osseointegration currently provides one of the best chances for any bilateral amputee to walk again and regain the ability to perform daily activities

Introduction. Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt. Materials & Methods. Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups. Results. These data suggest comparable outcomes between circular frames and alternative techniques can be achieved. A notable reduction in the number of circular frames applied during the review period was observed. Furthermore, frame fixation was associated with more frequent outpatient review and the associated implications for resource management. Conclusions. Conclusion: The Covid-19 pandemic has posed great challenges to the Trauma and Orthopaedic community, forcing us to be flexible by adopting alternative treatment methods to traditional circular external fixation. These alternatives have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted

Background. Treatment of staphylococcal prosthetic joint infection (PJI) usually consists of surgical debridement and prolonged rifampicin combination therapy. Tailored antimicrobial treatment alternatives are needed due to frequent side effects and drug-drug interactions with rifampicin combination therapy. We aimed to assess the effectiveness of several alternative antibiotic strategies in patients with staphylococcal PJI. Methods. In this prospective, multicenter registry-based study, all consecutive patients with a staphylococcal PJI, treated with DAIR or one-stage revision surgery between January 1. st. , 2015 and November 3. rd. , 2020, were included. Patients were treated according to a predefined protocol for PJI. Antimicrobial treatment strategies differed between centers, which was accepted and used as pseudorandomization. Depending on the hospital patients were admitted to, they were treated with either a long-term rifampicin strategy (consisting of 12 weeks rifampicin combination therapy) ore one of several short-term rifampicin strategies, consisting of only five days of rifampicin combination treatment, started immediately postoperative, followed by clindamycin, flucloxacillin or vancomycin monotherapy. Patients were stratified in different groups, depending on the used antimicrobial strategy. Cox proportional hazards models were used to compare outcome between the groups. Results. Two hundred patients were included and, based on the antimicrobial treatment, stratified in one long-term rifampicin group (n=23) or one of the three short-term rifampicin groups: clindamycin (n=56), flucloxacillin (n=47), vancomycin (n=26), other (n=48). Outcome of PJI after DAIR or one-stage exchange was not statistically different between patients treated with long-term rifampicin combination therapy and patients treated with clindamycin or flucloxacillin monotherapy including only five days of rifampicin combination therapy. Moreover, treatment duration was four weeks shorter in the clindamycin-based and flucloxacillin-based groups. Adjusted hazard ratios for failure for patients treated with either flucloxacillin or clindamycin were almost equal to patients treated with long-term rifampicin combination therapy (aHR 1.21, 95%CI 0.34–4.40). Conclusions. A short-term rifampicin strategy with either clindamycin or flucloxacillin and only five days of rifampicin was found to be as effective as traditional long-term rifampicin combination therapy. A randomized controlled trial is needed to further address efficacy and safety of alternative treatment strategies for staphylococcal PJI

Aim. The rise of multidrug-resistant bacteria and the decreasing efficacy of antibiotic therapy in successfully treating biofilm-associated infections are prompting the exploration of alternative treatment options. This study investigates the efficacy of different bioactive glass (BAG) formulations - alone or combined with vancomycin - to eradicate biofilm. Further, we study the influence of BAG on pH and osmotic pressure as important factors limiting bacterial growth. Method. Different BAG-S53P4 formulations were used for this study, including (a) BAG-powder (<45 μm), (b) BAG-granules (500–800 μm), (c) a cone-shaped BAG-scaffold and (d) two kinds of BAG-putty containing granules, with no powder (putty-A) or with additional powder (putty-B), and a synthetic binder. Inert glass beads were included as control. All formulations were tested in a concentration of 1750 g/ml in Müller-Hinton-Broth. Targeted bacteria included methicillin-resistant Staphylococcus aureus (MRSA) and epidermidis (MRSE). Vancomycin was tested at the minimum-inhibitory-concentration for each strain (1 µg/ml for MRSA; 2 μg/ml for MRSE). To investigate the antibiofilm effect of BAG alone or combined with vancomycin, 3 hour-old MRSA or MRSE biofilms were formed on porous glass beads and exposed to BAG ± vancomycin for 24h, 72h and 168h. After co-incubation, biofilm-beads were deep-washed in phosphate-buffered saline and placed in glass vials containing fresh medium. Recovering biofilm bacteria were detected by measuring growth-related heat production at 37°C for 24h by isothermal microcalorimetry. Changes in pH and osmotic pressure over time were assessed after co-incubation of each BAG formulation in Müller-Hinton-Broth for 0h, 24h, 72h and 168h. Results. All BAG formulations showed antibiofilm activity against MRSA and MRSE in a time-dependent manner, where longer incubation times revealed higher antibiofilm activity. BAG-powder and BAG-putty-B were the most effective formulations suppressing biofilm, followed by BAG-granules, BAG-scaffold and finally BAG-putty-A. The addition of vancomycin had no substantial impact on biofilm suppression. An increase in pH and osmotic pressure over time could be observed for all BAG formulations. BAG-powder reached the highest pH value of 12.5, whereas BAG-putty-A resulted in the lowest pH of 9. Both BAG-putty formulations displayed the greatest increase on osmotic pressure. Conclusions. BAG-S53P4 has demonstrated efficient biofilm suppression against MRSA and MRSE, especially in powder-containing formulations. Our data indicates no additional antibiofilm improvement with addition of vancomycin. Moreover, high pH appears to have a larger antimicrobial impact than high osmolarity. Acknowledgements. This work was supported by PRO-IMPLANT Foundation (Berlin, Germany). The tested materials were provided by Bonalive Biomaterials Ltd (Turku, Finland)

Prosthetic joint infection (PJI) is a severe complication of prosthetic joint implantation, with an estimated incidence of 2.18%. Most frequently used treatment strategy for PJI is a two-stage revision procedure. However there are specific patients with a new or persisting infection after primary or revision surgery where further surgical treatment is not attractive. This may be because of medical or local surgical conditions, or patient's refusal to undergo (further) surgical therapy. For these patients suppressive antibiotic therapy (SAT) may be an alternative treatment. The aim of this study is to describe the clinical and radiological outcome of patients with a PJI of a hip arthroplasty, treated with SAT. Twenty-four patients with a hip arthroplasty treated with suppressive antibiotic therapy for PJI between January 1, 2008 and December 31, 2013 were included. All patients had a proven prosthetic joint infection, either by ≥2 intraoperative cultures or joint aspiration. SAT was defined as treatment with antibiotic therapy for more than three months. Most used antibiotics were doxycycline in 15 patients and cotrimoxazole in six patients. Patients were supposed to have a successful outcome when their prosthesis remained in situ and they had no relapse or new infection. Suppressive antibiotic therapy was considered successful in 15 (62.5%) patients with a mean follow-up of 20.6 months. Two patients (8.3%) had to stop the antibiotic therapy due to adverse effects. The mean duration of the SAT was 20.4 months (range 0.92–92.65 months). Mean modified Oxford hip score of the successfully treated patients at the latest follow up was 35 (range 16–49) and mean Harris hip score 71 (range 40–93). The mean visual analogue scale (VAS) was 16 (range 0–70) in rest, 32 (range 0–85) during exercise and 65 (range 10–100) for satisfaction. Of the 9 patients with an unsuccessful outcome, there was a radiological loosening of the cup in 4 patients. In the group of 15 patients that were considered successful, 2 patients had a radiological loosening of the cup and one patient loosening of the stem. Suppressive antibiotic therapy can be an attractive alternative treatment in selected patients with a prosthetic joint infection of a hip arthroplasty who cannot or will not undergo (further) surgical therapy. Further research with a larger number of patients is required. Also the optimal dosage and duration of suppressive antibiotic therapy and possible resistance to the antibiotic therapy is unknown

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

INTRODUCTION. Lumbar total disc replacement (TDR) is an alternative treatment to avoid fusion related adverse events, specifically adjacent segment disease. New generation of elastomeric non-articulating devices have been developed to more effectively replicate the shock absorption and flexural stiffness of native disc. This study reports 5 years clinical and radiographic outcomes, range of motion and position of the center of rotation after a viscoelastic TDR. Material and methods. This prospective observational cohort study included 61 consecutive patients with monosegmental TDR. We selected patients with intermediate functional activity according to Baecke score. Hybrid constructs had been excluded. Only cases with complete clinical and radiological follow-up at 3, 6, 12, 24 and 60 months were included. Mean age at the time of surgery was 42.8 +7.7 years-old (27–60) and mean BMI was 24.2 kg/m² +3.4 (18–33). TDR level was L5-S1 in 39 cases and L4-L5 in 22 cases. The clinical evaluation was based on Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI) score, Short Form-36 (SF36) including physical component summary (PCS) and mental component summary (MCS) and General Health Questionnaire GHQ28. The radiological outcomes were range of motion and position of the center of rotation at the index and the adjacent levels and the adjacent disc height changes. Results. There was a significant improvement in VAS (3.3±2.5 versus 6.6±1.7, p<0.001), in ODI (20±17.9 versus 51.2±14.6, p<0.001), GHQ28 (52.6±15.5 versus 64.2±15.6, p<0.001), SF 36 PCS (58.8±4.8 versus 32.4±3.4, p<0.001) and SF 36 MCS(60.7±6 versus 42.3±3.4, p<0.001). Additional surgeries were performed in 5 cases. 3 additional procedures were initially planified in the surgical program: one adjacent L3-L5 ligamentoplasty above a L5S1 TDR and two L5S1 TDR cases had additional laminectomies. Fusion at the index level was secondary performed in 2 L4L5 TDR cases but the secondary posterior fusion did not bring improvement. In the 56 remaining patients none experienced facet joint pain. One patient with sacroiliac pain needed local injections. Radiological outcomes were studied on 56 cases (exclusion of 5 cases with additional surgeries). The mean location centers of the index level and adjacent discs were comparable to those previously published in asymptomatic patients. According to the definition of Ziegler, all of our cases remained grade 0 for disc height (within 25% of normal). Discussion. The silent block design of LP-ESP provides an interesting specificity. It could be the key factor that makes the difference regarding facets problems and instability reported with other implants experimentally or clinically. Unfortunately no other comparative TDR series are available yet in the literature. Conclusion. This series reports significant improvement in mid-term follow up after TDR which is consistent with previously published studies but with a lower rate of revision surgery and no adjacent level disease pathologies. The radiographic assessment of the patients demonstrated the quality of functional reconstruction of the lumbar spine after LP ESP viscoelastic disc replacement

Aim. Phage therapy has attracted attention as a promising alternative treatment option for biofilm infections. To establish a successful phage therapy, a comprehensive stock of different phages covering a broad bacterial spectrum is crucial. We screened human and environmental sources for presence of lytic phages against selected bacteria. Methods. Saliva collected from 10 volunteers and 500 ml of sewage water were screened for the presence of lytic phages active against 20 clinical strains of Staphylococcus aureus and 10 of Escherichia coli, both isolated from patients with prosthetic joint infection. Laboratory strains of methicillin-resistant S. aureus (MRSA)*1 and E. coli*2 were also tested. Screening was performed plaque-assay to detect phages for different strains. Isolated plaques were collected and phages were enriched to determine their activity against their bacterial host strains. The activity of bacteriophages against adherent E. coli and MRSA was evaluated by crystal violet, staining bacterial biofilms grown on glass beads. Results. Six bacteriophages specific for MRSA were isolated from saliva. Bacteriophages for E. coli strains were isolated from sewage water (n=3) and saliva (n=1). All bacteriophages tested against biofilms of their bacterial host showed a reduction of the total biomass (ranging from 19% to 84%). Conclusions. Both sewage and saliva samples provided bacteriophages specific against selected bacterial strains. 24h phage treatment of E. coli and S. aureus biofilms lead to a reduction but not to a complete eradication of biofilm

Glenohumeral osteoarthritis (OA) is a challenging clinical problem in young patients. Given the possibility of early glenoid component loosening in this population with total shoulder arthroplasty (TSA), and subsequent need for early revision, alternative treatment options are often recommended to provide pain relief and improved range of motion. While nonoperative modalities including nonsteroidal anti-inflammatory medications and physical therapy focusing on rotator cuff strengthening and scapular stabilization may provide some symptomatic relief, young patients with glenohumeral OA often need surgery for improved outcomes. Joint preserving techniques, such as arthroscopic debridement with removal of loose bodies and capsular release, with or without biceps tenotomy or tenodesis, remains a viable nonarthroplasty option in these patients. Clinical studies evaluating the outcomes of arthroscopic debridement for glenohumeral OA in young patients have had favorable outcomes. Evidence suggests that earlier stages of glenohumeral OA have more favorable outcomes with arthroscopic debridement procedures, with worse outcomes being observed in patients with complete joint space loss and bipolar chondral lesions. More advanced arthroscopic options include inferior osteophyte excision and axillary neurolysis or microfracture of chondral lesions, both of which have demonstrated favorable early clinical outcomes. Patients with some preserved joint space and small osteophytes can avoid arthroplasty and have improved functional outcomes after arthroscopic debridement for glenohumeral OA. Caution should be advised when indicating this procedure for patients with large osteophytes, grade IV bipolar lesions, biconcave glenoids, and complete loss of joint space

Arthrodesis of the first metatarsophalangeal joint (MTPJ) has been reported as gold standard for the treatment of advanced hallux rigidus and is a well-documented procedure. However, many patients demand a mobile MTPJ and therefore joint sparing procedures like MTPJ-arthroplasty have gained popularity. The aim of the present study was to present first mid-term results after hemiarthroplasty to treat advanced osteoarthritis of the first MTPJ. Between April 2006 and October 2013, a total of 81 hemiprostheses (AnaToemic®, Arthrex) in 71 consecutive patients (44 females, 27 male, 10 bilateral; mean age, 58 [range, 45–82]) were implanted at the St. Vincent Hospital Vienna (Austria). The indication for surgery was persistent MTPJ pain after failed conservative treatment combined with radiologic evidence of osteoarthritis (advanced hallux rigidus grade II-IV). Patients were clinically examined using the American Orthopaedic Foot and Ankle Society (AOFAS) score before surgery and at the final follow-up visit. Patient's satisfaction with the treatment was recorded. Radiological results were evaluated using standard x-rays and revision surgeries were documented. The mean preoperative AOFAS Scores significantly increased from 51 to 88 points after an average follow-up duration of 5 years (p<0.001). Most patients (76%) were either very satisfied or satisfied with the procedure. Radiological assessment showed some kind of radiolucencies on the base plate, whereas the stem of the prosthesis was well integrated in most of the cases; however clinical outcome was not affected by minor radiolucent lines on the base plate. In the majority of patients the implant was in situ at last follow-up. If revision surgery, due postoperative pain or implant loosening, was required; it occurred within 12 to 36 months. According to our promising mid-term results with a MTPJ-hemiprostheses, we conclude that MTPJ-arthroplasty is an effective alternative treatment modality for anatomical reconstruction of the first MTPJ with the benefit to reduce pain and maintain mobility

Lower-extremity orthopaedic procedures may be performed under either regional or general anaesthesia, or a combination of both techniques. There is a growing body of evidence supporting the benefits of regional anaesthesia, with meta-analyses of randomised controlled trials and registry data suggesting decreases in deep surgical site infections, thromboembolic events, cardiopulmonary complications and length of stay associated with use of regional anaesthesia. In patients undergoing foot and ankle surgery specifically, there is evidence demonstrating decreased post-operative pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports an increased role for the use in regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict the type of anaesthetic used in patients undergoing foot and ankle surgery. Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analysed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used. General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p<0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure (<0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 +/− 77 minutes, whereas patients provided with regional anaesthesia had a mean length of procedure 83 +/− 64 minutes. With increasing evidence supporting the benefits of regional anaesthesia in patients undergoing lower extremity surgery, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure may be a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be considered candidates for regional anaesthesia

There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The non-operative treatment of OA is often highly effective for all stages of the disease; 2) A non-operative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered. There are many potential causes of pain in an arthritic knee. These include intra-articular (e.g. degenerative meniscal tears, loose bodies, synovitis) and extra-articular (tendonitis, e.g. ilio-tibial band syndrome, bursitis, muscle overload syndromes and referred pain) sites. The potential sources of pain in an arthritic knee produce a wide range of symptoms that are not necessarily correlated with objective measurements (e.g. x-rays, MRI). Moreover, the natural history of an arthritic knee is unpredictable and variable. The treatment of the young, arthritic knee patient of all stages requires a systematic and consistent non-surgical approach. This approach includes the use of: 1) analgesics/anti-inflammatory agents; 2) activity modification; 3) alternative therapies; 4) exercise; 5) injections/lavage. The response to each form of non-surgical treatment is unpredictable at each stage (Kellgren 1–4) of OA. The placebo effect of each form of treatment, including the physician-patient interaction, is 50–60% in patients with mild-moderate OA. The components of a non-operative treatment program include: 1) Education-emphasizing the importance of the patient taking charge of his/her care; 2) Appropriate activity/life style modifications-emphasizing the importance of remaining active while avoiding activities that aggravate symptoms (e.g. running to biking); 3) Medications-oral, topical, intra-articular; 4) Physical therapy. There are extensive data to support each of these interventions. The AAOS has issued guidelines based upon a review of the literature-based effectiveness of conservative interventions

Introduction. Acetabular osteotomy is considered to be an alternative treatment for acetabular dysplasia, particularly in adolescents and young adults because the long-term results of total hip arthroplasty (THA) in such patients remain controversial. To our knowledge, few reports have described the relationship between the types of osteotomies and surgical difficulty. We compared the operative and clinical results of THA following the 3 main types of acetabular osteotomies, including Chiari osteotomy, rotational periacetabular osteotomy (RAO), and shelf acetabuloplasty. Methods. Operative records of 13 hips following Chiari osteotomy (Chiari group), 22 hips following RAO (RAO group), and 16 hips following shelf acetabuloplasty (Shelf group) were retrospectively reviewed. Operative records of 2475 primary THAs without previous osteotomies during the same period were reviewed as a control. The direct anterior approach was used for all hips. Results. The mean operative time was 57.7 ± 11.7 min in the Chiari group, 68.7 ± 25.7 min in the RAO group, 57.4 ± 20.5 min in the shelf group, and 50.6 ± 18.5 min in the Control group. The operative time was significantly longer in the RAO group than in the Control group (p < 0.05). The mean operative blood loss was 406 ± 277 g in the Chiari group, 439 ± 400 g in the RAO group, 377 ± 163 g in the Shelf group, and 379 ± 270 g in the Control group. Allogeneic blood transfusion was performed in 1 patient (4%) in the RAO group and in 26 patients (1%) in the Control group. Bulk bone augmentation to the acetabular defect was performed in 2 hips (15%) in the Chiari group, 7 hips (32%) in the RAO group, and 87 hips (3.5%) in the Control group. The requirement for bulk bone augmentation to the acetabular defect was significantly higher in the Chiari and RAO groups than in the Control group (p < 0.05). Aseptic loosening occurred in 2 cups in the RAO group and postoperative dislocation occurred in 1 hip in the Chiari group. Conclusion. RAO made the conversion to THA complicated because of acetabular defects. Chiari osteotomy was less effective and shelf acetabuloplasty had no effect on surgical results of conversion THA

Introduction. The management of peri-prosthetic distal femur fractures following TKR (Total Knee Replacement) in the elderly remains a challenge with little or no consensus on the best available treatment. Various methods have been described in the management of these complex fractures. Our study compares the outcome and cost of distal femoral arthroplasty to that of Fixation (Plating/Retrograde Nailing). Methods. We retrospectively reviewed our database for patients admitted with peri-prosthetic distal femoral fractures between 2005–2013 (n=61). The patients were stratified into 2 groups based on method of management. The Distal Femoral Arthroplasty group (Group A) had 21 patients, with a mean age of 78 years (68–90. The Fixation group (Group B) had 40 patients, with a mean age of 74 years, 23 of those had plating of the fracture, while 17 had a retrograde nail inserted. Pain scores, Length of stay, intra-operative blood loss, and weight bearing status, were compared. Functional outcomes were also assessed using Oxford knee scores, KSS scores, VAS pain assessment and range of motion from last follow up appointment. Minimum follow-up was 2 years. Cost analysis was done for both groups, which included implant costs, consumable costs (man power included), theatre utilisation time and length of hospital stay. The calculation was done based on the PbR (payment by results) system and “best practise tariffs 2010–11” utilised by the NHS (National Health Service) in England. Results. In group A, the average surgical time was 116 minutes with mean blood loss of 400 ml. In group B, the mean surgical time was 123 minutes with average blood loss of 800 ml. The mean length of hospital stay in group A was 9 days whereas in group B was 32 days. All patients were fully weight bearing by day 1.5(range 1–3 days) in group A, compared to a mean of 11 weeks in group B. Mean Oxford score was 28 and KSS score was 70 in group A compared to 27 and 68 in group B. The pain score on VAS was 2 for group A and 1.5 for group B. The mean ROM of the knee was 95° in group A and 85° in group B. We had 4 complications in group A. There were 2 deaths due to medical co-morbidities, 1 superficial infection, and 1 DVT. In the fixation group, there were 6 deaths due to medical co-morbidities, 1 failure of fixation, 6 mal-unions, 1 non-union and 2 infections. Overall, the distal femoral arthroplasty procedure costs approximately £10000, and the fixation group costs were on average of £9800. Discussion & Conclusion. Distal femoral arthroplasty allowed early mobilisation, thus avoiding prolonged hospital stay and reducing the risk of inpatient related morbidity. Complication rates were lower than the fixation group and the overall costs were comparable to that of fixation. Distal femoral arthroplasty appears to be a promising alternative treatment to internal fixation in elderly patients with distal femoral peri-prosthetic fractures. With appropriate patient selection, the prosthesis is likely to survive for the duration of patient's lifetime

Prosthetic implants, periprosthetic and osteoarticular tissues are specimens of choice for diagnosis of bone and joint infections including prosthetic joint infections (PJIs). However, it is widely known that cultures from prostheses and tissues may fail to yield microbial growth in up to one third of patients. In the recent past, treatment of prosthetic implants have been optimized in order to improve sensitivity of microbiological cultures, while less attention has been addressed to tissue samples. For these latter homogenization is considered the best procedure, but it is quite laborious, time-consuming and it is not always performed in all laboratories. Dithiothreitol (DTT) has been proposed as an alternative treatment to sonication for microbiological diagnosis of PJIs. In this study, we evaluated the applicability of MicroDTTect treatment, a closed system developed for transport and treatment of tissues and prosthetic implants with DTT. For evaluation of applicability of MicroDTTect to tissue specimens, samples (tissues and, in case of PJI, prosthetic implants) from 40 patients (12 PJIs and 5 osteomyelitis and 23 not-infected) were evaluated. MicroDTTect system consists of a sterile plastic bag containing a reservoir which allows for release of a 0.1% (v:v) DTT solution, once the sample is placed into the bag. Comparison of MicroDTTect treatment of prostheses with sonication included samples from 30 patients (14 with aseptic loosening of the prosthesis and 16 with PJIs). Of two tissue samples from the same region, one was placed into MicroDTTect bag and the other was collected in a sterile container with addition of sterile saline. After agitation and centrifugation of the eluate, aliquots of the pellets were plated on agar plates and inoculated into broths which were incubated for 48 hrs and 15 days, respectively. Treatment of prosthetic implants with MicroDTTect showed a higher specificity and sensitivity than sonication (specificity 92.8% vs 85.7%; sensitivity: 87.5% vs 75.0 % DTT vs sonication). When used for tissue treatment, MicroDTTect showed a sensitivity of 82.3% and a specificity of 97% which were higher than that observed when saline was used (sensitivity: 64.7%; specificity 91%). Treatment of tissues and prosthetic implants with MicroDTTect may be a practicable strategy to improve microbiological diagnosis of osteoarticular infections, reducing sample manipulation and therefore limiting sample contamination. Moreover, use of MicroDTTect does not require dedicated instrumentation, and is time and cost saving

Despite numerous advances in the management of chronic osteomyelitis, many questions remain. To date, no evidence-based guidelines exist in the treatment of chronic osteomyelitis. In essence the aim is to improve quality of life through either a curative or a palliative treatment strategy. The choice of treatment strategy is based on the physiological status of the host. This process of host stratification is, however, complicated by the fact that the definition of a C-host has never been standardized. Purpose;. The aim of the study was to investigate the short term outcome of the treatment of chronic osteomyelitis in adult patients where selection of a management strategy was based on a refined host stratification system. Methods;. A retrospective review was performed of adult patients with chronic osteomyelitis seen over a one year period. In total 116 patients were included in the study. A modified host stratification system was applied, incorporating predefined major and minor criteria, to determine each patient's host status. Results;. A high prevalence of HIV infection (28.6%) and malnutrition (15%) was present in the study population. Almost half the patients were classified as C-hosts (44.8% or n=52), followed by B-host classification in 39.7% of cases (n=46). At a mean follow-up of one year an overall success rate of 91.4% (95% CI: 84.7–95.8%) was achieved. Host status and outcome (remission, suppression or failure) was significantly dependent (p-value < 0.001). Success was achieved in 92.2% of patients treated curatively and 89.6% of patients treated palliatively. Conclusion;. By integrating the physiological status of the host (based on objective predefined criteria) with the appropriate curative, palliative or alternative treatment strategy we were able to achieve acceptable outcomes in both low and high risk cases and, in addition, avoid unnecessary amputation

Background:. Two-stage reconstruction, reimplantation after removal of an infected prosthesis, has been considered to be the gold standard for treatment of infected hip arthroplasty. However, during the removal of a well-fixed femoral stem, the proximal femur can be damaged and a sequestrum can be formed, which might lead to chronic osteomyelitis and difficulty in reimplantation. We wanted to determine whether infection after hip arthroplasty can be treated without removal of a well-fixed stem. Materials and Methods:. We treated 19 patients who had an infection after hip replacement, but a well-fixed cementless stem, with 2-stage reconstruction. At the first stage, we removed the acetabular cup, the liner and the head, but not the stem. We then implanted a cup of cement spacer. After control of infection, we reimplanted the acetabular component and head. Results:. 2 patients did not undergo second-stage reconstruction because they were satisfied with the pain relief and the activity that they had with the cement-spacer implantation. The remaining 17 patients underwent the second-stage of the reconstruction using cementless arthroplasty. At a mean follow-up time of 4 (2–8) years, 15 of the patients had no recurrence of infection, with satisfactory clinical and radiographic outcome. Discussion:. This second-stage reconstruction after retention of the stem could be an alternative treatment option for periprosthetic infection with a well-fixed stem

There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The nonoperative treatment of OA is often highly effective for all stages of the disease; 2) A nonoperative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered. There are many potential causes of pain in an arthritic knee. These include intra-articular (e.g. degenerative meniscal tears, loose bodies, synovitis) and extra-articular (tendonitis, e.g. ilio-tibial band syndrome, bursitis, muscle overload syndromes and referred pain) sites. The potential sources of pain in an arthritic knee produce a wide range of symptoms that are not necessarily correlated with objective measurements (e.g. x-rays, MRI). Moreover, the natural history of an arthritic knee is unpredictable and variable. The treatment of the young, arthritic knee patient of all stages requires a systematic and consistent non-surgical approach. This approach includes the use of: 1) analgesics/anti-inflammatory agents; 2) activity modification; 3) alternative therapies; 4) exercise; 5) injections/lavage. The response to each form of non-surgical treatment is unpredictable at each stage (Kellgren 1–4) of OA. The placebo effect of each from of treatment, including the physician-patient interaction, is 50–60% in patients with mild-moderate OA. The components of a nonoperative treatment program include: 1) Education-emphasising the importance of the patient taking charge of his/her care; 2) Appropriate activity/life style modifications-emphasising the importance of remaining active while avoiding activities that aggravate symptoms (e.g. running to biking); 3) medications-oral, topical, intra-articular; 4) Physical therapy. There are extensive data to support each of these interventions. The AAOS has issued guidelines highlighted the literature based effectiveness of conservative interventions