Advertisement for orthosearch.org.uk
Results 1 - 20 of 24
Results per page:
Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 263 - 263
1 Dec 2013
Qadir R Sidhu S Ochsner JL Meyer MS Chimento G
Full Access

Introduction:. Deep infection after total joint arthroplasty is a devastating complication with reported incidence of 1–3% with projection to increase to 6.8% by 2030. The direct costs of revision surgery due to septic failure are estimated at over $55,000 per case. Antibiotic-Loaded Bone Cement (ALBC) has been proposed as a preventive measure to decrease post-operative infection rates. Its efficacy has been compared with plain bone cement (PBC) in multiple studies. There has been no study to our knowledge examining its efficacy in “high risk” patients. The purpose of this study is to compare infection rates in three cohorts of patients: (1) all patients receiving only PBC, (2) all patients receiving only ALBC, and (3) only “high risk” patients receiving ALBC. Methods:. A standard cement protocol was instituted at our hospital for primary total knee arthroplasties (pTKA). From January 2000 to 2005 all pTKAs were performed with PBC. From February 2005 to May 2010, all pTKAs were performed with ALBC. From June 2010 to March 2012, all patients received regular bone cement unless they had previous diagnoses of rheumatoid arthritis, obesity, and/or diabetes mellitus. Our institutional joint registry was queried and the three cohorts' individual charts were retrospectively reviewed. Infection rates amongst cohorts were compared at 30 days, 6 months, and 1 year from index surgery date utilizing two sided proportion tests. Results:. A total of 3,292 consecutive primary TKAs with full follow up were included. Overall infection rate at one year for the entire study was 0.76%. There were 1,025 patients who received PBC, 1486 ALBC, and 781 in the risk stratified cohort. The 30-day infection rates for cohorts 1, 2, 3 were .0.29%, 0.20%, and 0.13% respectively. The 6-month infection rates for cohorts 1, 2, 3 were 0.39%, 0.54% and 0.38% respectively. The 1-year infection rate for cohorts 1, 2, 3 were 0.78%, 0.61%, and 0.64% respectively. The differences in infection rates between each cohort at all three time intervals were not statistically significant. Conclusions:. Antibiotic loaded bone cement does not significantly decrease infection rates for primary total knee arthroplasty. Even risk stratified usage of ALBC for “high risk” patients may be unnecessary and add undue costs to both the patient and hospital, without any appreciable benefit


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_4 | Pages 3 - 3
1 Apr 2019
Rastogi D Dwivedi MK
Full Access

Introduction. Periprosthetic joint infection (PJI) is a serious problem and requires great effort and cost for its treatment. Treatment options may vary from resection arthroplasty, retention of prosthesis with debridement, one stage revision and two stage revision with handmade antibiotic impregnated cement spacer or with prefabricated antibiotic loaded cement spacer. Two stage revision remains the gold standard for the treatment of periprosthetic joint infection after Total Hip Arthroplasty (THA). This study was aimed to find the efficacy and cost effectiveness of handmade antibiotic impregnated articulating cement spacer over commercially available prefabricated antibiotic loaded cement spacer for the treatment of deep PJI of hip prosthesis and to evaluate its functional outcome. Material and methods. A total of 23 PJI patients were enrolled in this prospective cohort study. In the two stages of revision, the first stage consisted of thorough debridement, implant removal and implantation of handmade articulating antibiotic impregnated cement spacer. The second stage surgery consisted of removal of cement spacer, thorough debridement and implantation of new prosthesis. All patients were followed for a period of 24 months. Results. A total of 23 patients (15 males and 8 females) underwent two stage revision arthroplasty for chronic periprosthetic joint infection. The mean age of the patient was 57 years. The handmade antibiotic impregnated cement spacer was retained for 16– 20 weeks. Common organism observed was coagulase negative staphylococci followed by Staphylococcus aureus. After an average follow up of 2 years, 20 patients with PJI remained clinically free of infection. In 2 patients there was recurrence of infection. Conclusion. We conclude that two stage revision by hand made cement spacer is successful in eradication of infection with satisfactory functional outcome. Furthermore, these handmade cement spacer are cost effective and their efficacy may be comparable to commercially available prefabricated spacer


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 68 - 68
1 Oct 2022
Bos K Spekenbrink-Spooren A Reijman M Bierma-Zeinstra S Croughs P v. Oldenrijk J
Full Access

Aim. Aim was to compare revision rates when using single versus dual antibiotic loaded cement (ABLC) in hip fracture arthroplasty and aseptic revision hip or knee arthroplasty using data from the Dutch national joint registry (LROI). Methods. All primary cemented (hemi-)arthroplasties for acute hip fractures and cemented aseptic hip or knee revision arthroplasties, were incorporated in 3 datasets. All registered implants between 2007 and 2018 were included (minimum 2 years follow-up). Primary end-point was subsequent revision rates for infection and for any reason in the single and dual ABLC groups. Cumulative crude incidence of revision was calculated using competing risk analysis. Results. A total of 22,308 hip fracture arthroplasties, 2,529 hip revision and 7,124 knee revision arthroplasties were registered and analyzed in the study period. The majority of hip fracture patients (97.1%) was treated with single ABLC. For hip and knee revision arthroplasties dual ABLC was used in 33.8% and 25.7%. The revision rate for infection in the fracture arthroplasty group was not different between groups (0.5% versus 0.8%, p=0.27). The re-revision rate following hip or knee revision based on single versus dual ABLC was not different between groups (3.2% versus 2.8%, p=0.82 for hip revision and 1.8% versus 2.5%, p=0.36 for knee revision). In addition, the re-revision rate for any reason was not different in all three datasets. The crude cumulative revision and re-revision rates for any reason based on single ABLC versus dual ABLC showed no differences in all three datasets. The crude cumulative 7-year re-revision rate for any reason following revision THA with Gentamicin ABLC use was 11.8%, with Gentamicin + Clindamycin ABLC use 13.1% and with Erythromycin + Colistin ABLC use 14.8% (ns). The crude cumulative 9-year re-revision rate for any reason following revision TKA with Gentamicin ABLC use was 17.7% and with Gentamicin + Clindamycin ABLC use 16.5% (ns). Conclusions. In conclusion, we could not show a difference in revision rate for hip fracture arthroplasty or re-revision rates for revision hip- or knee arthroplasty with the use of dual ABLC compared to single ABLC bone cement, with 7and 9 year follow up. The low percentage of dual ABLC in hip fracture arthroplasties in our registry do not enable us to make a reliable estimation of the added value in this patient category. The results of this study do not confirm the potential benefit of dual ABLC use in revision cases


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_10 | Pages 91 - 91
1 Jun 2018
Haddad F
Full Access

The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a suboptimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. For most patients, antibiotics alone are not an acceptable method of treatment, and surgery is necessary. The standard of care for established infection is two stage revision with antibiotic loaded cement during the interval period and parental antibiotic therapy for six weeks. Single stage revision may have economic and functional advantages, however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors. Our protocol has included single stage revision using antibiotic loaded cement in both THA and TKA. This was only undertaken when sensitive organisms were identified pre-operatively by aspiration and appropriate antibiotics were available to use in cement. Patients with immunocompromise, multiple infecting organisms or recurrent infection were excluded. Patients with extensive bone loss that required allograft reconstruction or where a cementless femoral component was necessary were also excluded. Our algorithm was validated first in the hip and extended to infected TKA in 2004. This protocol has now been applied in over 100 TKA revisions for infection between 2004 and 2009. Our single stage revision rate is now over 25%. We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two stage revision cases. Whilst our indications are arbitrary and not based on specific biomarkers, we present excellent results for selective single stage exchange. A minimum three year follow-up suggests that these patients have shorter hospital stays, higher satisfaction rates and better knee scores. An ongoing evaluation is in place. One stage revision arthroplasty for infection offers potential clinical and economic advantages in selected patients


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 37 - 37
1 Mar 2013
Cho W
Full Access

Revision of infected TKA is one of the most challenging operation as the surgeon should achieve two goals, ie eradication of infection and restoration of function. For the eradication of infection, a minimum of two operations are needed in most of cases. First stage of revision is meticulous debridement and insertion of antibiotic loaded cement. During arthrotomy, thick fibrous and granulation tissues which is located in the suprapatella pouch, lateral site to the patella tendon and posterior joint space should be removed so as to get better exposure, to get rid of infection source and to get better functional result. During debridement, I use highly concentrated antibiotic saline (1 gm vancomycin in 10cc saline), for irrigation of the operation field. I also pack the opening of the medullary canal so as to prevent the debris from entering into the medullary canal. I use antibiotics with the ratio of 1:3. To reduce the dead space in the medullary canal I insert a dowel shaped antibiotic loaded cement spacer made from one pack of cement and fill the medullary canal. Thereafter two packs of cement are used to make a block to fill the gap between femur and tibia. The cement block should be large enough to cover the distal femur and proximal tibia so as not to cause bone defect and knee dislocation during walking. After first stage of operation, antibiotics are administered for 4∼8 wks until the CRP levels become normalized and clinical findings show no sign of infection. The 2. nd. stage of operation is planned when clinical and laboratory signs of infection subside. The decision whether to reimplant the prosthesis or not is based on the operation findings and polymorphonuclear cell count on frozen section. However operation findings are considered more important than the frozen section results for reimplantation. If operative findings are clean, I do reimplanation even though the polymorphonuclear cell count is more than 5 on high power field(hpf) on frozen section. I have adopted numbering system to take specimen. Number 1 is specimen from suprapatella pouch, No 2 is that from gap between the femur and tibia, No 3 is that from femoral intramedullary canal, No 4 is that from tibial intramedullary canal, and No 5 is that from most unhealthy site. In a retrospective analysis of 16 cases which received reimplantation despite of the prescence of more than five polymorphonuclear cells on intra-operative frozen sections, none of the cases had recurrence of infection at a final follow up of 2 years. The femoral medullary canal was the most prevalent site for higher polymorphonuclear cell count. In conclusion, indication is the first step for successful reimplantion. Two stage revision is recommended and meticulous debridement is utmost important in first stage operation. Block type antibiotic loaded cement is sufficient for a good result. Clinical, laboratory and operative findings are more important than polymorphonuclear cell count on frozen section to decide reimplantation. I propose numbering system of the specimen site for frozen section, just as in tumor surgery


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_17 | Pages 59 - 59
1 Nov 2016
Haddad F
Full Access

The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a suboptimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. For most patients, antibiotics alone are not an acceptable method of treatment, and surgery is necessary. The standard of care for established infection is two-stage revision with antibiotic loaded cement during the interval period and parental antibiotic therapy for six weeks. Single stage revision may have economic and functional advantages however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors. Our protocol has included single stage revision using antibiotic loaded cement in both THA and TKA. This was only undertaken when sensitive organisms were identified pre-operatively by aspiration and appropriate antibiotics were available to use in cement. Patients with immunocompromise, multiple infecting organisms or recurrent infection were excluded. Patients with extensive bone loss that required allograft reconstruction or where a cementless femoral component was necessary were also excluded. Our algorithm was validated first in the hip and extended to infected TKA in 2004. This protocol has now been applied in over 100 TKA revisions for infection between 2004 and 2009. Our single stage revision rate is now over 25%. We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two-stage revision cases. Whilst our indications are arbitrary and not based on specific biomarkers, we present excellent results for selective single stage exchange. A minimum three-year follow-up suggests that these patients have shorter hospital stays, higher satisfaction rates and better knee scores. An ongoing evaluation is in place. One-stage revision arthroplasty for infection offers potential clinical and economic advantages in selected patients


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_8 | Pages 66 - 66
1 May 2014
Haddad F
Full Access

The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a sub optimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. For most patients, antibiotics alone are not an acceptable method of treatment, and surgery is necessary. The standard of care for established infection is two stage revision with antibiotic loaded cement during the interval period and parental antibiotic therapy for six weeks. Single stage revision may have economic and functional advantages however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors. Our protocol has included single stage revision using antibiotic loaded cement in both THA and TKA. This was only undertaken when sensitive organisms were identified preoperatively by aspiration and appropriate antibiotics were available to use in cement. Patients with immunocompromise, multiple infecting organisms or recurrent infection were excluded. Patients with extensive bone loss that required allograft reconstruction or where a cementless femoral component was necessary were also excluded. Our algorithm was validated first in the knee and extended to infected TKA in 2004. This protocol has now been applied in over 100 TKA revisions for infection between 2004 and 2009. Our single stage revision rate is now over 25%. We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two stage revision cases. Whilst our indications are arbitrary and not based on specific biomarkers, we present excellent results for selective single stage exchange. A minimum three year follow-up suggests that these patients have shorter hospital stays, higher satisfaction rates and better knee scores. An ongoing evaluation is in place. One stage revision arthroplasty for infection offers potential clinical and economic advantages in selected patients


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_6 | Pages 13 - 13
1 Jul 2020
Wildeman B Bormann N Beuttel E Pobloth A Duda GN
Full Access

Despite the increasing availability of bone grafting materials, the regeneration of large bone defects remains a challenge. Especially infection prevention while fostering regeneration is a crucial issue. Therefore, loading of grafting material with antibiotics for direct delivery to the site of need is desired. This study evaluates the concept of local delivery using in vitro and in vivo investigations. We aim at verifying safety and reliability of a perioperative enrichment procedure of demineralized bone matrix (DBM) with gentamicin. DBM (DBMputty, DIZG, Germany) was mixed with antibiotic using a syringe with an integrated mixing propeller (Medmix Systems, Switzerland). Gentamicin, as powder or solution, was mixed with DBM at different concentrations (25 −100 mg/g DBM), release and cytotoxicity was analyzed. For in vivo analysis, sterile drill hole defects (diameter: 6 mm, depth: 15 mm) were created in diaphyseal and metaphyseal bones of sheep (Pobloth et al. 2016). Defects (6 – 8 per group and time point) were filled with DBM or DBM enriched with gentamicin (50 mg/g DBM) or left untreated. After three and nine weeks, defect regeneration was analyzed by µCT and histology. The release experiments revealed a burst release of gentamicin from DBM independent of the used amount, the sampling strategy, or the formulation (powder or solution). Gentamicin was almost completely released after three days in all set-ups. Eluates showed an antimicrobial activity against S. aureus over at least three days. Eluates had no negative effect on viability and alkaline phosphatase activity of osteoblast-like cells (partially published Bormann et al. 2014). µCT and histology of the drill hole defects revealed a reduced bone formation with gentamicin loaded DBM. After nine weeks significantly less mineralized tissue was detectable in metaphyseal defects of the gentamicin group. Histological evaluation revealed new bone formation starting at the edges of the drill holes and growing into the center over time. The amount of DBM decreased over time due to the active removal by osteoclasts while osteoblasts formed new bone. Using this mixing procedure, loading of DBM was fast, reliable and possible during surgical setting. In vitro experiments revealed a burst and almost complete release after three days, antimicrobial activity and good biocompatibility of the eluates. Gentamicin/DBM concentration was in the range of clinically used antibiotic-loaded-cement for prophylaxis and treatment in joint replacement (Jiranek et al. 2006). The delayed healing seen in vivo was unexpected due to the good biocompatibility found in vitro. A reduced healing was also seen in spinal fusion where DBM was mixed with vancomycin (Shields et al. 2017), whereas DBM with gentamicin or DBM/bioactive glass with tobramycin had no negative effect on osteoinductivity or femur defect healing, respectively (Lewis et al. 2010, Shields et al. 2016). In conclusion, loading of DBM with gentamicin showed a proper antibiotic delivery over several days, covering the critical phase shortly after surgery. Due to the faster and complete release of the antibiotic compared to antibiotic loaded cement, the amount of antibiotic should be much lower in the DBM compared to cement


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_17 | Pages 36 - 36
1 Dec 2018
Dhoshi K Kumar A Palanivel A
Full Access

Aim. To assess the effectiveness of role of frozen section in revision arthroplasty. Method. 21 patients with infected hip arthroplasties were operated in the form of one or two-staged revision hip arthroplasties. A frozen section was obtained intra-operatively and >5 PMN's/ HPF was considered as a positive indicator of infection. Fig 1 llustrating frozen section image. If the frozen section was reported negative (≤5 PMN's/HPF), the revision prosthesis was implanted after a thorough debridement and a wash. If the frozen section was reported as positive, after the debridement a non-articulating antibiotic loaded cement spacer was implanted for 8 weeks, supplemented with 3 weeks of intravenous antibiotics and 3 weeks of oral antibiotics. This was followed by an antibiotic free interval of 2 weeks. The patient was taken up for a revision surgery once the frozen section study was negative (≤5 PMN's/HPF). The patients were followed up for minimum of 1 year to a maximum of 2 years after the revision for any evidence of infection (assessed clinically and serologically, radiologically). Results. 15 patients had a positive frozen section (>5PMN's/HPF) in the first stage and were treated with prosthesis removal and cement spacer insertion for 8 weeks. In the 2nd stage, out of 15 patients, 14 underwent revision arthroplasty, while 1 patient underwent reapplication of the cement spacer. As per the follow up of ESR & CRP values, clinically and radiologically no patients had any evidence of infection. The average follow up was 17.04 months (range 12–24 months). 1 patient had persistently raised ESR (34mm/hr) which may be attributable to other causes Frozen section analysis of PMN's per high power field had 100% specificity in our patients in detecting periprosthetic joint infection. Conclusions. Intraoperative frozen section study is a reliable indicator in predicting a diagnosis of PJI with good accuracy in ruling out this diagnosis. Frozen section study should thus be considered a relevant part of the challenging diagnostic work-up for patients undergoing revision hip arthroplasty


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_5 | Pages 64 - 64
1 Mar 2017
Oh B Cho W Cho H Lee G
Full Access

Purpose. Failure resulting from a recurrent infection in total knee arthroplasty (TKA) is a challenging problem. Knee arthrodesis is one treatment option, however fusion is not always successful, as there is huge bone defect. The authors reports a new arthrodesis technique that uses a bundle of flexible intramedullary rods and an antibiotic-loaded cement spacer. Methods. There were 13 cases of arthrodesis due to recurrent periprosthetic joint infection, which were performed by the first author (WS Cho) at Asan Medical Center in Seoul from 2005 to 2014. All previous prosthetic components were removed and cement was thoroughly excised using a small osteotome. Two stage operation was done in most of cases. After thorough debridement, antibiotics loaded cement was inserted in first stage, flexible intramedullary rods were inserted retrogradely in the femoral side with the knee in flexion under fluoroscopy guidance. After filling the femoral intramedullary canal, the rods were then driven back securely into the tibial medullary canal. We aimed for as much rod length as possible to maximize stability. After 6 weeks of first stage operation, the rods of the femoral and tibial sides were arranged such that they overlapped and interdigitated to maximize mechanical strength, maintain the limb length and keep the rotational alignment. The interdigitating rod ends were tightly fixed using two (or three) cerclage wires. Antibiotic-loaded cement was filled into the knee joint space so that the cement is fit to the irregular contour of the femur and tibia, which was resulted from the severe bone loss. Postoperatively, patients were allowed to weight bear as tolerated. Results. The procedure was successful in every cases with no evidence of rod or cement failure at least 1 year follow up. Also there was no recurrence of infection. Conclusion. Although this simple method was not for bony union, the authors could achieve stable knee joint without recurrence of infection


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_22 | Pages 59 - 59
1 Dec 2017
Frapwell C Duignan C Webb J Aiken S Cooper J Stoodley P Howlin R
Full Access

Aim. Bacterial biofilms play a key role in prosthetic infection (PI) pathogenesis. Establishment of the biofilm phenotype confers the bacteria with significant tolerance to systemic antibiotics and the host immune system meaning thorough debridement and prosthesis removal often remain the only possible course of treatment. Protection of the prosthesis and dead-space management may be achieved through the use of antibiotic loaded cements and beads to release high concentrations of antibiotics at the surgical site. The antibacterial and antibiofilm efficacy of these materials is poorly understood in the context of mixed species models, such as are often encountered clinically. Methods. A P. aeruginosa and S. aureus in vitro co-culture biofilm model was grown using 1/5th BHI supplemented with 20 µM hemin. The ability of beads made from a synthetic calcium sulfate (CaSO4) loaded with vancomycin, tobramycin and vancomycin & tobramycin in combination to prevent biofilm formation and kill established co-culture biofilms were assessed using viable cell counts and confocal scanning laser microscopy (CSLM) over a 7 day time course. To assay for genetic changes to the individual species as a result of their presence together within a biofilm, mutation rates were measured using fluctuation analysis following growth as planktonic and biofilm cultures, alone or in co-culture. Mutants were determined based on their ability to grow on agar plates containing an inhibitory concentration of rifampicin. Mutation rates were calculated using the Ma-Sandri-Sarkar Maximum Likelihood Estimator and 94% confidence intervals compared for significance. Results. Mixed species biofilms displayed differential sensitivity to vancomycin alone and tobramycin alone CaSO4-loaded beads relative to single species biofilms. Preliminary data suggests 10- and 100-fold increase in mutation rates of P. aeruginosa and S. aureus, respectively, when in a co-culture relative to monospecies biofilm which, while further work is needed, may directly or indirectly contribute to the differing antibiotic sensitivities observed. A broad-spectrum intervention of CaSO4-loaded vancomycin & tobramycin beads was able to prevent bacterial colonisation and attenuate P. aeruginosa and S. aureus mixed species biofilm formation for multiple days. Conclusions. Synthetic antibiotic-loaded CS beads, with a broad-spectrum antibiotic combination, have potential to reduce or eliminate mixed species biofilm formation on implant material by providing locally high concentrations over sufficient time periods to aid in the management of PIs. * Stimulan, Biocomposites Ltd


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 121 - 121
1 Dec 2015
Marega L Gnagni P
Full Access

The use of a cemented implant instead of a spacer has been proposed due to the improved function in comparison with a spacer. Unfortunately the removal of a conventional cemented stem can be challenging. The use of a short cemented stem can overcome this problem. Between July 2011 and May 2013, 10 infected hips were treated with a short cemented stem as a spacer. The infected implants were cemented in 6 cases and cementless in 4 cases. Mean time from index operation was 3 years (range 0 to 8 years). It was the first treatment for infection in all cases. Antibiotic loaded cement and an all-poly cup was used in all cases. The bugs were staph aureus and staph epidermidis in most cases. A Friendly short cemented stem with specific cement restrictor and standard cementing tecnique was used in all cases. This stem has been successfully tested in over 200 patients and approved by TUV to be released on the marked. In all cases, the infection was successfully cured with antibiotics for a period ranging from 3 to 5 months. 2 patients were revised after the infection was cured for recurrent dislocation. No recurrent infection was found at the latest follow up. One stage revision is gaining in popularity for the decreased morbidity and better quality of life of the patients. Weak points of one-stage revision are slightly inferior results in terms of eradication of the infection and the fact that it can be done only with cemented implants. Cemented implants show inferior durability than cementless implants and are difficult to remove if revision is needed. The use of a short cemented stem can couple the advantages of one stage revision and the fact that it is easily removed if this is needed for various reasons (aseptic loosening, recurrent dislocation and periprosthetic fracture). Contraindications to this technique are severe bone loss in the acetabulum or in the proximal femur


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_23 | Pages 14 - 14
1 Dec 2016
Schoop R Gerlach U Sonja M
Full Access

Aim. Which patients is bone-defect-reconstruction with the Masquelet-technique suitable and which problems did we see?. Method. From 11/2011 to 4/2016 we treated 49 Patients (12f/37m) with bone-defects up to 150mm after septic complications with the Masquelet-technique. We had infected-non-unions of upper and lower extremity, chronic osteomyelitis, infected knee-arthrodesis and upper-ancle-empyema. On average the patients were 48 (8–74) years old. The mean bone-defect-size was 60 mm (25–150). From other hospitals came 47 of the 49 patient, where they had up to 20 (mean 4,9) operations caused by the infection. The time before transfer to our hospital was on average 177days (6–720). 40 patients receaved flaps because of soft tissue-defects (12 free flaps, 28 local flaps). 21 patients suffered a polytrauma. In 8 cases the femur, in 4 cases a knee-arthrodesis, in 34 cases tibia, in 2 cases humerus and in 1 case the ulna were infected resulting in bone defects. Indication for the Masquelet-technique was low-/incompliance in 35 cases due to higher grade of traumatic brain injury and polytrauma and difficult soft-tissue conditions, in 9 times problems with segment-transport and in 5 cases as dead space management. Positive microbial detection succeeded in 32 patients at the first operation. Mainly we found difficult to treat bacteria. After treating the infection with radical sequestrectomy, removal of foreign bodies and filling the defect with antibiotic loaded cement spacer and external fixation we removed the spacer6–8 weeks later and filled the defect with bone graft. In 23 cases we stabilized the defect then with an internal angle stable plate. All patients were examined clinically and radiologically every 4–6 weeks in our outpatient-department until full weight bearing, later every 3 months. Results. In 41 of 49 cases the infection was clinically treated successfully. 21 patients are allowed for full weight bearing (all with secondary internal plates). There were 8 recurrences of infection, 22 instabilities needing internal stabilization and further bone graft. We saw “Plate-breaks” in 4 cases. 2 patients underwent amputation. Conclusions. For patients with low-/incompliance for various reasons and for those with difficult soft tissue conditions following flaps the Masquelet technique is a valuable alternative to the normal bone graft and to the segment transport. The stiffness of the new Masquelet bone like a rod is a problem. Internal fixation is often necessary


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_15 | Pages 32 - 32
1 Dec 2015
Barreira P Neves P Serrano P Leite P Sousa R
Full Access

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


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_23 | Pages 34 - 34
1 Dec 2016
Gbejuade H Hidalgo-Arroy A Sayers A Leeming J Lovering A Blom A Webb J
Full Access

Aim. To evaluate the ability of different combinations of antibiotic loaded cement to inhibit bacteria growth and biofilm formation. Method. Cement beads were aseptically prepared using Palacos R (plain 40g PMMA cement) or Palacos R+G (40g PMMA cement containing industrially added 0.5g of gentamicin), with or without supplementary antibiotics as follows: Palacos R; Palacos R+G; Palacos R plus 1g / 2g daptomycin; Palacos R+G plus 1g / 2g of daptomycin; Palacos R plus 1g / 2g vancomcyin; and Palacos R+G plus 1g / 2g vancomycin. After production, each antibiotic loaded acrylic cement (ALAC) combination was allocated into two groups (group 1 and 2). The group 2 cement beads were initially eluted in broth at 37. o. C for 72hours then transferred to fresh broth containing a known concentration of bacteria. The group 1 samples were not eluted but directly immerse in culture broth containing bacteria. All samples were thereafter incubated at 37. o. C for 24 hours. After incubation, group 1 samples were visually assessed for bacterial growth, while for the group 2 samples, biofilm formation were quantified using ultrasonication and viable bacteria counting technique. Three proficient biofilm forming Staphylococcus epidermidis bacterial strains (1457, 1585-RA and 5179-R1) were used for all experiments and the bacteria counts were expressed as colony forming units / ml (CFU/ml). Results. In the group 1 samples, all the ALAC combinations were able to inhibit growth of all the three biofilm bacteria strains assessed except the gentamicin only samples in which biofilm growth were observed within 24hours. Meanwhile, in group 2, bacterial growth and biofilm formation by all three bacterial strains were observed on all the ALAC combinations, with the least biofilm formation being on the Palacos R+G plus 2g daptomycin combinations (mean CFU/ml: 1.04E +06) and the greatest on the gentamicin only cement (mean CFU/ml: 2.3E +07). Conclusions. Our study demonstrates that the highest antimicrobial activity of ALAC is seen in the first 24 hours. However, after 72 hours of antibiotic release, fresh bacterial exposure in fresh broth resulted in varying degrees of biofilm colonisation of all ALAC surfaces. Nonetheless, the overall biofilm formation was least on the gentamicin / daptomycin combinations and the results were statistically significant when compared to plain cement (p < 0.05, two tail t-test)


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 20 - 20
1 Feb 2012
Chesney D Sales J Elton R Brenkel I
Full Access

Introduction. We report the results of a prospective study of 1349 patients undergoing 1509 total knee replacements, identifying factors increasing the risk of infection. Methods. Data were collected prospectively between October 1998 and February 2002 by a dedicated audit nurse. Pre-operative demographic and medical details were recorded. Operative and post-operative complications were noted. The definitions of surgical-site infection were based on a modification of those published by the Centre for Disease Control (CDC) in 1992. A superficial wound infection had a purulent discharge or positive culture of organisms from aseptically-aspirated fluid, tissue, or from a swab. Deep infection was counted as an infection that required a secondary procedure. Patients were seen at 6, 18 and 36 months post-operatively in a dedicated knee audit clinic and infection details recorded. The association between infection and other factors was tested by chi-squared or Mann-Whitney tests for categorised or quantitative factors respectively. Results. 18 patients (1.2% of all total knee replacements) had deep infection and a further 49 suffered a superficial infection. We found no correlation between risk of infection and age, sex, BMI, ASA grade, tourniquet time, lateral release, surgeon, transfusion or the need for catheterisation in the early post-operative period. Diabetic patients had an increased odds ratio for deep and superficial infection, but these results did not reach statistical significance. Only 3 of the 49 superficial infections went onto develop a deep infection at an average of 21 months after surgery. Conclusion. Using modern orthopaedic surgical techniques including laminar flow theatres, systemic antibiotics and antibiotic loaded cement, the risk of infection following TKR is 1.2%. There is a mildly increased risk of infection in diabetics. Catheterisation with antibiotic cover does not increase the risk of infection


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_22 | Pages 66 - 66
1 May 2013
Della Valle C
Full Access

A “two-stage exchange” remains the gold standard for treatment of the infected THA in North America. Although there is interest in “one-stage exchange” this technique is predicated on the use of fixation of the revision implants with antibiotic loaded cement, which is not as popular in North America. Diagnosis is critical and in general consists of a screening serum ESR and CRP followed by selective aspiration if the above are abnormal and/or if the clinical history is suspicious. The aspirated fluid is sent for a synovial fluid WBC (cut-off approximately 3,000 WBC/μL), differential (cut-off 80% PMN) and culture. The basic tenets of treatment include: . Thorough debridement of all infected appearing cement and all foreign material. Placement of an interval antibiotic loaded spacer (note that the addition of antibiotics to bone cement is NOT FDA approved). –. 4–6 g of antibiotics per pkg of cement; typically vancomycin + tobramycin. –. Higher viscosity cement may be associated with higher elution. –. Higher elution with combination of antibiotics. Antibiotic spacers can be “articulating” or “static”. Potential advantages of an articulating spacer include greater patient comfort and an easier approach at the second stage exchange as leg length and soft tissue tension is maintained. However, these spacers are oftentimes more costly and can dislocate. May not be appropriate in cases where there is severe bone loss that cannot support partial weight bearing or if the abductors are compromised (higher risk of dislocation). The first stage is followed by approximately 6 weeks of organism specific IV antibiotics. An interdisciplinary approach with an infectious disease specialist, internal medicine and a nutritionist optimises outcomes. Our protocol then includes weekly ESR and CRP to monitor their trend. These labs are re-checked two weeks after cessation of antibiotics to ensure the trend has not changed. We have found that while the ESR and CRP are significantly lower than prior to the 1st stage, they often times DO NOT normalise and there is no specific cut-off value that predicts persistent infection. An intra-operative aspiration for synovial fluid WBC count and differential is obtained intra-operatively (cut-off values of approximately 3,000 WBC/μl and 80% PMN) and are the best tests to identify persistent infection


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_19 | Pages 16 - 16
1 Apr 2013
Shah A Badge R Joshi Y Choudhary N Sochart D
Full Access

Introduction. Negative remodelling of the femoral cortex in the form of calcar resorption due to stress shielding and cortical hypertrophy at the level of the tip of the implant, due to distal load transfer, is frequently noted following cemented total hip replacement, most commonly with composite beam implants, but also with polished double tapers. The C-stem polished femoral component was designed with a third taper running from lateral to medial across and along the entire length of the implant, with the aim of achieving more proximal and therefore more natural loading of the femur. The hoop stresses generated in the cement mantle are transferred to the proximal bone starting at the calcar, which should theoretically minimise stress-shielding and calcar resorption, as well as reducing distal load transfer, as signified by the development of distal femoral cortical hypertrophy. Materials/Methods. We present the results of a consecutive series of 500 total hip replacements performed between March 2000 and December 2005 at a single institution, using a standard surgical technique and third generation cementing with Palacos-R antibiotic loaded cement. Data was collected prospectively and the patients remain under annual follow-up. 500 arthroplasties were performed on 455 patients with an average age of 68.3 years (23–92). 77 patients have died (73 arthroplasties) and the average duration of follow-up for the entire series is 81 months (52–124). Results. Only 2 femoral implants have been revised - one for deep sepsis and the other as part of a revision procedure for a loose acetabulum, although the femoral component itself was not loose. One implant is currently loose following a periprosthetic fracture treated by internal fixation, but none of the other remaining implants demonstrates any progressive radiolucencies in any Gruen zones, or any features suggestive of current or future loosening. Rounding of the calcar has been observed, but there have been no cases with obvious loss of calcar height and no cases of distal femoral cortical hypertrophy. Conclusion. The C-stem femoral component has therefore performed well in clinical practice and the objective of eradicating negative bone remodelling has been achieved. The study is ongoing


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 25 - 25
1 Mar 2013
Bruni D Iacono F Presti ML Sharma B Raspugli G Marcacci M
Full Access

INTRODUCTION. Conventional surgical exposures are usually inadequate for 2-stage revision knee replacement ofinfected implants. Reduced range of motion, extensor mechanism stiffness, peripatellar contracture and soft tissue scarring make patellar eversion difficult and forced eversion places the integrity of the extensor mechanism at risk. On the contrary, a wide exposure is fundamental to allow complete cement spacer removal, soft tissue balancing, management of bone loss and reimplantation without damaging periarticular soft tissues. OBJECTIVES. To compare the long-term clinical, functional and radiographic results and the reinfection rate of the quadriceps snip approach and the tibial tubercle osteotomy in 2-stage revision knee replacement performed for septic loosening of the primary implant. METHODS. In our department, 87 patients had a 2 stage revision knee replacement for septic loosening of the primary implant between 1996 and 2008. In all patients, first stage consisted of primary implant removal, extensive soft tissue debridement and positioning of a static antibiotic loaded cement spacer. The timing for reimplantation was decided basing on negative clinical and laboratory (ESR, CRP) signs and negative Leukoscan results. For reimplantation, a quadriceps snip was used in patients with an intraoperative flexion >90° (Group A) while a tibial tubercle osteotomy (Group B) was used in patients with an intraoperative flexion <90°. RESULTS. At observation point, 4 patients died for reasons unrelated to surgery, leaving 42 patients in Group A and 41 in Group B. We had a total amount of 10 recurrent infections (11%) after reimplantation, 7 patients in Group A and 3 patients in Group B (p<0.005). Patients with a reinfection in Group A were treated with a knee fusion in 4 cases, a rerevision in 2 cases and an amputation above the knee in 1 case, while all those with a reinfection in Group B had a knee fusion. According to HSS score, 11 patients were rated as Excelent/Good in Group A and 9 patients in Group B (p=n.s.). Three patients had a major complication in Group A and 0 patients in Group B (p=0.005). No differences were found between the two groups regarding range of motion and subjective satisfaction. CONCLUSION. Tibial tubercle osteotomy is a safe procedure to obtain a wide exposure in 2-stage revision knee replacement performed for septic loosening of the primary implant and it is effective in reducing reinfection rate without compromising clinical results and range of motion


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXV | Pages 220 - 220
1 Jun 2012
Sochart D Chaudhary N
Full Access

Negative remodelling of the femoral cortex in the form of calcar resorption due to stress-shielding, and femoral cortical hypertrophy at the level of the tip of the implant due to distal load transfer, is frequenly noted following cemented total hip replacement, most commonly with composite beam implants, but also with polished double tapered components. The C-stem polished femoral component was designed with a third taper running from lateral to medial across and along the entire length of the implant, with the aim of achieving more proximal and therefore more natural loading of the femur. The implant is designed to subside within the femoral cement mantle utilising the cement property of creep, generating hoop stresses, which are transferred more proximally to the femoral bone, starting at the level of the medial calcar. The intention is to load the proximal femur minimising stress-shielding and calcar resorption, as well as reducing distal load transfer as signified by the lack of distal femoral cortical hypertrophy. We present the results of a consecutive series of 500 total hip replacements using C-stem femoral components, performed between March 2000 and December 2005 at a single institution. Data was collected prospectively and all patients remain under annual follow-up by a Specialist Arthroplasty Practitioner. The operations were performed using a standard surgical technique with third generation cementing using Palacos-R antibiotic loaded cement. 500 arthroplasties were performed on 455 patients with an average age at the time of surgery of 68.3 years (23-92). There were 282 (62%) female and 173 (38%) male patients with osteoarthritis being the predominant diagnosis. 77 patients have died (73 hips) and the average duration of follow-up for the entire series is 81 months (52-124). Only 2 femoral implants have been revised - one for deep sepsis and the other as part of a revision procedure for a loose acetabulum, although the femoral component itself was not loose. One implant is currently loose following a periprosthetic fracture treated by internal fixation, but none of the remaining implants demonstrates any progressive radiolucencies in any Gruen zones or any features suggestive of current or future loosening. Calcar rounding has been observed, but there have been no cases with obvious loss of calcar height and no cases of distal femoral cortical hypertrophy. The C-stem femoral component has therefore performed well in clinical practice and the objective of eradicating negative bone remodelling has been achieved. The study is ongoing