Introduction. While total knee arthroplasty (TKA) improves postoperative function and relieves pain in the majority of patients with end stage osteoarthritis, its ability to restore normal knee kinematics is debated. Cadaveric studies using computer-assisted orthopaedic surgery (CAOS) system [1] are one of the most commonly used methods in the assessment of post-TKA knee kinematics. Commonly, these studies are performed with an open arthrotomy; which may impact the knee kinematics. The purpose of this cadaveric study was to compare the knee kinematics before and after (open or closed) arthrotomy. Materials and Methods. Kinematics of seven non-arthritic, fresh-frozen cadaveric knees (PCL presumably intact) was evaluated using a custom software application in an image-free CAOS system (ExactechGPS, Blue-Ortho, Grenoble, FR). Prior to the surgical incision, one tracker was attached to the diaphysis of each tibia and femur. Native intact knee kinematics was then assessed by performing passive range of motion (ROM) three separate times, from full extension to at least 110 degrees of flexion, with the CAOS system measuring and recording anatomical values, including flexion angle, internal-external (IE) rotation and anterior-posterior (AP) translation of the tibia relatively to the femur, and the hip-knee-ankle (HKA) angle. Next, an anterior incision with a medial parapatellar arthrotomy was performed, followed by acquisition of the anatomical landmarks used for establishing an anatomical coordinate system in which all the anatomical values were evaluated [2]. The passive ROM test was then repeated with closed and then open arthrotomy (patella manually maintained in the trochlea groove). The anatomical values before and after knee arthrotomy were compared over the range of knee flexion using the native knee values as the baseline. Results. Generally, kinematics from the native knee were found to be similar to those with closed and open arthrotomy. Deviations between native knee and arthrotomy groups (open or closed, whichever was the worst case) were 0.49±0.52mm for the AP translation, 0.44±0.41° for the HKA, and 0.86±0.8° for the IE rotation (Figures 1–3). The deviation from native knee kinematics was found to be higher with increased flexion angles in both HKA and AP translation. Closing the arthrotomy had minimal effect on knee kinematics, and no difference was seen in knee kinematics between an open and closed arthrotomy, so long as the patella is manually maintained within the trochlear groove. Discussion. This study demonstrated arthrotomy, whether open or closed, did not affect the tested knee kinematics compared to a native intact knee. The deviation found in the anatomical values was within the typical range of clinical variation. Increased deviation in high flexion for some anatomical values may be due to difficulty in reproducing consistent motion during ROM test. This study showed that an open arthrotomy with the patella maintained in the trochlea groove provides accurate assessment of the intact knee kinematics

Although total knee arthroplasty (TKA) is a largely successful procedure to treat end-stage knee osteoarthritis (OA), some studies have shown postoperative abnormal knee kinematics. Computer assisted orthopaedic surgery (CAOS) technology has been used to understand preoperative knee kinematics with an open joint (arthrotomy). However, limited information is available on the impact of arthrotomy on the knee kinematics. This study compared knee kinematics before and after arthrotomy to the native knee using a CAOS system. Kinematics of a healthy knee from a fresh frozen cadaver with presumably intact PCL were evaluated using a custom software application in an image-free CAOS system (ExactechGPS, Blue-Ortho, Grenoble, FR). At the beginning of the test, four metal hooks were inserted into the knee away from the joint line (one on each side of the proximal tibia and the distal femur) for the application of 50N compressive load to simulate natural knee joint. Prior to incision, one tracker was attached to each tibia and femur on the diaphysis. Intact knee kinematics were recorded using the CAOS system by performing passive range of motion 3 times. Next, a computer-assisted TKA procedure was initiated with acquisition of the anatomical landmarks. The system calculated the previously recorded kinematics within the coordinate system defined by the landmarks. The test was then repeated with closed arthrotomy, and again with open arthrotomy with patella maintained in the trochlea groove. The average femorotibial AP displacement and rotation, and HKA angle before and after knee arthrotomy were compared over the range of knee flexion. Statistical analysis (ANOVA) was performed on the data at ∼0° (5°), 30°, 60°, 90° and 120° flexion. The intact knee kinematics were found to be similar to the kinematics with closed and open arthrotomy. Differences between the three situations were found, in average, as less than 0.25° (±0.2) in HKA, 0.7mm (±0.4) in femorotibial AP displacement and 2.3° (±1.4) in femorotibial rotation. Although some statistically significant differences were found, especially in the rotation of the tibia for low and high knee flexion angles, the majority is less than 1°/mm, and therefore clinically irrelevant. This study suggested that open and closed arthrotomy do not significantly alter the kinematics compared to the native intact knee (low RMS). Maintaining the patella in the trochlea groove with an open arthrotomy allows accurate assessment of the intact knee kinematics

Septic arthritis is a therapeutic emergency with a high mortality rate (about 11%)(1). Inadequate treatment can cause permanent joint damage. Management of the septic arthritis includes prompt antibiotic treatment as well as joint-decompression and removal of purulent material(2). It is still discussed controversially and there is little evidence which surgical concept is preferable: arthroscopy with lavage and debridement or open arthrotomy with synovectomy(3,4). The aim of the study was to compare efficacy of arthroscopy and arthrotomy in patients with septic gonarthritis. We evaluated 70 consecutive patients who underwent arthroscopy or arthrotomy at our clinic, because of a bacterial monarthritis of the knee between 2002 and 2010. Our primary outcome was the early recurrence of infection (> 3 months after surgery), which made a second surgery necessary. We compared patients who suffered reinfection and those who did not, in regard to the surgery type as well as potential confounders like comorbidity (measured by Charlson comorbidity index), age, body mass index (BMI), Gächter's -, Kellgren and Lawrence - and Outerbridge classification, duration of symptoms and inflammatory parameters. Furthermore we evaluated differences of the confounders between the surgery groups. From the 70 patients 41 were treated arthroscopic and 29 with arthrotomy. In total eight patients (11.4%) had to undergo a second surgery because of early reinfection. The rate was significantly higher in patients treated with arthrotomy (n=6; 20.7%) compared to those treated with arthroscopy (n=2; 4.9%) (p=0.041). Whereas we found no significant influence of potential confounders between the reinfection group and the group where primary eradication was achieved. Patients who underwent arthrotomy were significantly older, had more comorbidities (both p<0.001) and higher grades of osteoarthritis according to Kellgren and Lawrence classification (p=0.023). In order to adjust the study population towards confounders we performed a subgroup analysis on patients of the second and third age percentile. When we repeated our analysis we still found a significant higher reinfection rate in the arthrotomy group (p=0.036). At the same time there were no differences in prevalence of confounders, neither between the two surgery groups, nor between the reinfection and the primary eradication group. Patients with bacterial monarthritis of the knee who were treated with arthroscopy had a significantly lower reinfection rate than those treated with arthrotomy. As arthroscopy is the less invasive and more sufficient method it should be considered the routine treatment according to our data

Purpose of the study: Joint puncture-wash-out is generally recommended for septic arthritis in children, but the debate is still open concerning the proper attitude for the hip joint. The purpose of this work was to examine our failure cases after treatment of septic hip arthritis using the puncture-wash-out option. We wanted to know whether first-intention primary arthrotomy might be a valid option. Material and methods: We reviewed retrospective 29 cases of septic hip arthritis treated initially by puncture-wash-out between January 1996 and June 2003. We excluded all cases of first intention arthrotomy. The series included 19 boys and ten girls aged four years three months on average at time of diagnosis (age range 8 months to 9 years). Mean follow-up was one year five months (range 1 month the 4 years). Mean delay to diagnosis was two days (range 0–6 days). In addition to intravenous antibiotics, the 29 hips were drained and washed out with saline solution under general anesthesia until a clear wash-out was obtained. Surgical revision (arthrotomy) was required for seven patients within 3 to 21 days. Results: Outcome was assessed at days 2, 5, and 10. Assessment variables were pain relief, normal blood tests, and apyrexia. Seven children required surgical revision for arthrotomy due to persistent clinical or biological disorders. Cure was achieved after all seven arthrotomies. At last follow-up, there was no difference, clinically or radiographically, between the children treated by puncture-wash-out or by arthrotomy. The factors which appeared to be the most significant to distinguish the two groups were, at admission: time to diagnosis and management greater than four days and C-reactive protein > 100. On day 5, the most significant factors were persistent joint pain and C-reactive protein > 100. Discussion: These results suggest that puncture-wash-out remains a simple and reliable treatment but that it has its limitations: a synovial biopsy cannot be obtained, visual examination of the joint cartilage is not possible, trepanation of the metaphysis is not possible. Our factors favoring poorer outcome are similar to those reported in the literature to which can be added age less than one year. When these factors are present, first-intention arthrotomy should be discussed

Introduction. Success of TKR depends upon soft tissue balance and component alignment. The alteration of quadriceps mechanism while approaching knee for TKR can affect outcome of the surgery. Aim. To analyse the results of Trivector retaining arthrotomy for TKR. Methods. A prospective study of 448 cases between 2008–2011. All the cases were performed by the author. Inclusion criteria: Primary TKR with any degree of deformity. Exclusion criteria: Revision TKR. Patients operated previously with a parapatellar arthrotomy. Surgical Technique – Approach includes dividing distal 30% of VMO along with medial retinaculum 1 cm. medial to patella distally up to the Tibial tuberosity, raised as a single flap. Patella is everted with knee in extension. Knee flexed to expose the knee articulation and rest of the arthroplasty carried out. The closure of the arthrotomy is by 1 no. vicryl interrupted stitches. (video clipping). Results. None of the cases were lost to FU. 258 cases Varus + FFD, 153 Varus alone, 21 Valgus, 11 hyperextension deformity and 5 neutral alignment cases were included. Results showed 87% pt.s at 1. st. postop day and 96% by 4. th. day regained ability to perform unassisted SLR. 4% had 5 to 10 degree quadriceps lag at discharge which recovered to neutral by 4 wks. The surgical field was adequate in all cases and did not have to be extended the arthrotomy incision. KSS score improved from av. Pre op of 54 (38–71) to an average post op of 93 (84–96). All patients by 7 to 10 days were walking unaided or with a single cane in case of Bilateral TKRs. Discussion. Medial parapatellar arthrotomy divides the quadriceps tendon. The alteration in various vector limbs of Quadriceps can change the balance and laterally maltrack the patella. Incidence of Lateral release is higher in this group. Subvastus approach is non extensile and hence poor visibility during surgery. Incidence of malalignment is higher in this group. Trivector retaining arthrotomy approach is extensile and retains 70% strength of vastus medialis. At the closure the quads mechanism is perfectly aligned and hence the incidence of lateral maltracking and lateral release minimised. It is easily reproducible and can be used in stiff knees, severe varus, valgus, obese and post HTO TKRs with consistent results. The 4% cases who had quadriceps lag were probably transient neuropraxia to the muscular branch of the medial superior genicular nerve. They all recovered at 4 wks. Follow up. Conclusion. The extensile nature of the approach and minimal disruption of the quadriceps mechanism encourages us to use this approach for all our cases. It is a true mechanically sound approach for all knees for TKRs

We performed a prospective, randomised study to compare the results and rates of complications of primary total knee replacement performed using a quadriceps-sparing technique or a standard arthrotomy in 120 patients who had bilateral total knee replacements carried out under the same anaesthetic. The clinical results, pain scales, surgical and hospital data, post-operative complications and radiological results were compared. No significant differences were found between the two groups with respect to the blood loss, knee score, function score, pain scale, range of movement or radiological findings. In contrast, the operating time (p = 0.0001) and the tourniquet time (p < 0.0001) were significantly longer in the quadriceps-sparing group, as was the rate of complications (p = 0.0468). We therefore recommend the use of a standard arthrotomy with the shortest possible skin incision for total knee replacement

Introduction:. During TKR it is mandatory to achieve perfect soft tissue balance and component alignment. As knee is covered in front by quadriceps mechanism, there is some manipulation of this structure while approaching knee for an arthroplasty. This alteration in Quadriceps mechanism can affect outcome of the surgery. Aim:. To analyze the results of Trivector arthrotomy for TKR surgery. Methods:. It is a study of 526 cases between 2008–2012. All the cases were performed by the author. Inclusion criteria: Primary TKR with any degree of deformity. Exclusion criteria: Revision TKR. Very fragile and thin patients. Surgical Technique – Approach includes dividing distal 30% of vastus medialis, medial retinaculum 1 cm. medial to patella and patellar tendon distally up to Tibial tuberosity. This is raised as a single flap with knee in flexion. Patella is everted with knee in extension. Knee flexed and routine arthroplasty carried out. The watertight closure of the arthrotomy is by 1 no. vicryl interrupted stitches. (video clipping). Results:. None of the cases were lost to FU. 323 cases Varus + FFD, 149 Varus, 35 Valgus, 14 hyperextension deformity, 5 neutral alignment cases were included. Results showed 87% pt.s at 1. st. postop day and 96% by 4. th. day regained ability to perform unassisted SLR. 4% had 5 to 10 degree quadriceps lag at discharge which recovered to neutral by 4 wks. The surgical field was adequate in all cases. KSS score improved from av. Pre op of 56 (38–71) to an average post op of 92 (84–96). All patients by 7 to 10 days were walking unaided or with a single cane in case of Bilateral TKRs. Discussion:. Medial parapatellar arthrotomy divides the quadriceps tendon. The alteration in various vector limbs of Quadriceps can change the balance and laterally maltrack the patella. Incidence of Lateral release is higher in Medial parapatellar arthrotomy cases. Mid and subvastus approaches are non extensile and hence poor visibility during surgery. Incidence of malalignment is higher when the visibility is poor. Trivector arthrotomy approach is extensile and retains 70% strength of vastus medialis. At the closure the quads mechanism is perfectly aligned and hence the incidence of lateral release minimized. It is easily reproducible and can be used in stiff knees, severe varus, valgus, obese and post HTO TKRs with consistent results. Conclusion:. The extensile nature of the approach and minimal disruption of the quadriceps mechanism encourages us to use this approach for all our cases. It is a true “Gateway” for all knees for TKRs

Aims. Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. Methods. A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. Results. A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. Conclusion. Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702–1708

Introduction. Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function. Methods. Two hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001-2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient-based measures of EuroQol and SF-36. All outcomes were measured pre-operatively and 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications. Results. Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay. Conclusion. There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained

Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function. Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications. Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay. Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained

Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function. Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications. Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay. Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained

The purpose of current study was to describe the results of complex acetabular fractures treated with open reduction using transtrochanteric approach and arthrotomy of the hip joint. Fourteen consecutive patients with both column fractures of the acetabulum were treated with open reduction and internal fixation. All patients had various associated injuries. Among them, one patient had pelvic abscess associated with traumatic bowel perforation. The acetabulum was approached with Y-shaped triradiate incision, osteotomy of the greater trochanter, and arthrotomy of the hip joint. During the operation, the osteochondral fragments were removed and torn labrum was resected. In 6 patients the fracture was fixed with reconstruction plates and in 8 patients the fracture was fixed with plates and wires. All the patients were followed for an average of 4.6 years(range, 2–8 years). The clinical evaluation was done by the method of Merle d’Aubigne. All the fractures and all osteotomies united at the latest follow up. One patient had delayed hematogenous infection at 5.5 years after the operation. Although myositis ossificans developed in 3 patients it was neither progressive after 1 year nor associated with significant limitation of hip motion. Four patients had narrowing of the hip joint space. Three of them had osteophyte formation around the femoral head. No femoral head necrosis was observed. Eleven patients had excellent or good outcomes in clinical score. No patient underwent total hip arthroplasty. This extensile approach allowed a good exposure of the fracture site, more accurate reduction, and easier fixation of fracture fragments. It also allowed the removal of osteochondral fragments and the resection of torn labrum. However, 3 patients showed osteophyte formation around the femoral head. We are concerned about the further progression of the osteophyte and its clinical implication

Aims: The purpose of the paper is to compare results of reconstruction of ACL with quadrupled ST and GR tendons via arthrotomy in the study group and arthroscopy in the control group. Methods: Treatment results of the consecutive cohort of 26 patients in the study group treated by arthrotomy were compared to the results of the consecutive cohort of 22 patients in the control group treated by arthroscopy operated between September 2002 and December 2003 by the same operating team. The patient’s age varied from 17 to 46 years (mean 24,5y) in the study group and 18 to 48 years (mean 23,7y) in the control group, with minimum follow-ups longer than 30 months. For the evaluation clinical examination, Lysholm& Gillquist and Marshall scales and KT-1000 assessment were used. For the proximal fixation endo-button plate and for the distal screw-post fixation were applied. There were no differences in graft harvesting, graft preparation and rehabilitation protocol in both groups. Results: There were 3 traumatic graft failures in the study group. Mean gained Lysholm& Gillquist score in the study group was 31,42(+−4,68SD) and mean gained Marshall score was 12,18(+−2,27SD). 57.69% of the patients in the study group returned to the sport and work without any limitation on the preoperative level, additional 30.76% has only minor limitation in sport or work. There was 1 case of superficial infection and 1 deep infection in the study group. Both infections resolved without sequels. MM lesions in 10 cases (38,46%) and no LM lesions were found intraoperatively. There were 2 traumatic and 1 unclear graft failures in the control group. Mean gained Lysholm& Gillquist score was 34,35(+−8,86SD) and mean gained Marshall score was 12,33(+−2,88SD). 45,46% of the patients in the control group returned to the unlimited sport and work on the preoperative level, additional 36,37% has minor limitation in sport or work and 1 patient despite stable knee was unable to return to the work. There was 1 case of deep vein thrombosis of the operated leg and 1 neuroma in the arthroscopy portal area in the control group. MM lesions in 12 cases (54,5%) and LM lesions in 5 cases (22,7%) were found intraoperatively. The average KT-1000 side-to-side difference in the study group was 2,88 mm and in the control group 2,73 mm. Conclusions: Mid-time follow-up reveals good to very good clinical outcome in both groups with no statistically significant differences. It looks interesting why the better average return to sport ratio was gained in the study group. 2 cases of infection discourage this approach except necessity additional cartilage repair. Differences in meniscal injuries rate might also advocate for arthroscopy as more capable in diagnose and treatment

Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and systemic lead poisoning. The literature is sparse on this subject, with mostly sporadic case reports utilizing hip arthroscopy. We report on the largest series of removal of bullets from the hip joints using open surgical. We reviewed prospectively collected data of patients who presented to a single institution with civilian gunshot injuries that breached the hip joint between 01 January 2009 and 31 December 2022. We included all cases where the bullet was retained within the hip joint area. Exclusion criteria: cases where the hip joint was not breached, bullets were not retained around the hip area or cases with isolated acetabulum involvement. One hundred and eighteen (118) patients were identified. One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Of the remaining 117 patients, 70 had retained bullets around the hip joint. In 44 patients we undertook bullet removal using the followingsurgical hip dislocation (n = 18), hip arthrotomy (n = 18), removal at site of fracture fixation/replacement (n = 2), posterior wall osteotomy (n = 1), direct removal without capsulotomy (tractotomy) (n = 5). In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove (n=4), patients’ clinical condition did not allow for further surgery (n= 4) and patient refusal (n=1). No patients underwent hip arthroscopy. With adequate pre-operative imaging and surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy; using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation

Aims. Delayed postoperative inoculation of orthopaedic implants with persistent wound drainage or bacterial seeding of a haematoma can result in periprosthetic joint infection (PJI). The aim of this in vivo study was to compare the efficacy of vancomycin powder with vancomycin-eluting calcium sulphate beads in preventing PJI due to delayed inoculation. Methods. A mouse model of PJI of the knee was used. Mice were randomized into groups with intervention at the time of surgery (postoperative day (POD) 0): a sterile control (SC; n = 6); infected control (IC; n = 15); systemic vancomycin (SV; n = 9); vancomycin powder (VP; n = 21); and vancomycin bead (VB; n = 19) groups. Delayed inoculation was introduced during an arthrotomy on POD 7 with 1 × 10. 5. colony-forming units (CFUs) of a bioluminescent strain of Staphylococcus aureus. The bacterial burden was monitored using bioluminescence in vivo. All mice were killed on POD 21. Implants and soft-tissue were harvested and sonicated for analysis of the CFUs. Results. The mean in vivo bioluminescence in the VB group was significantly lower on POD 8 and POD 10 compared with the other groups. There was a significant 1.3-log. 10. (95%) and 1.5-log. 10. (97%) reduction in mean soft-tissue CFUs in the VB group compared with the VP and IC groups (3.6 × 10. 3. vs 7.0 × 10. 4. ; p = 0.022; 3.6 × 10. 3. vs 1.0 × 10. 5. ; p = 0.007, respectively) at POD 21. There was a significant 1.6-log. 10. (98%) reduction in mean implant CFUs in the VB group compared with the IC group (1.3 × 10. 0. vs 4.7 × 10. 1. , respectively; p = 0.038). Combined soft-tissue and implant infection was prevented in 10 of 19 mice (53%) in the VB group as opposed to 5 of 21 (24%) in the VP group, 3 of 15 (20%) in the IC group, and 0% in the SV group. Conclusion. In our in vivo mouse model, antibiotic-releasing calcium sulphate beads appeared to outperform vancomycin powder alone in lowering the bacterial burden and preventing soft-tissue and implant infections. Cite this article: Bone Joint J 2024;106-B(6):632–638

Background. There are limited data on the complication rates and risk of periprosthetic joint infection (PJI) in patients who have an acute wound dehiscence after total knee arthroplasty (TKA). Methods. From 2002 to 2018, 16,134 primary TKAs were performed at a single institution. Twenty-six patients (0.1%) had a traumatic wound dehiscence within the first 30 days. Mean age was 68, 38% were female, and mean BMI was 33 kg/m2. Median time to dehiscence was 13 days. The dehiscence resulted from a fall in 22 cases, including 4 in-hospital falls (3 with femoral nerve blocks), and sudden flexion after staple removal in 4 cases. The arthrotomy was disrupted in 58%, including a complete extensor mechanism disruption in 4 knees. A surgical debridement was performed within 48 hours in 19 of 26 knees. Two-thirds were discharged on antibiotic therapy. Results. Only two knees were complicated by PJI (cumulative incidence of 11% vs. 1% in all other primary TKAs, HR 6.5, p <0.01). One patient who developed a PJI was initially treated with a bedside closure in the ER rather than surgical debridement. The second patient had a complete extensor mechanism disruption at the time of dehiscence and was treated with surgical debridement, but did not receive a subsequent course of antibiotics. There were no PJIs in any of the cases that were treated with surgical debridement and a course of antibiotics. Three knees required reoperation (cumulative incidence of reoperation was 16% at 2 years, compared to 6% in all other primary TKAs, p=0.32) including 1 two-stage exchange for PJI, 1 irrigation and debridement with component retention for PJI, and 1 revision for tibial component aseptic loosening. Conclusion. Despite having a traumatic wound dehiscence, with nearly 60% resulting in arthrotomies that exposed implants, the risk of PJI was low but significantly higher than not having a traumatic arthrotomy. We recommend urgent surgical irrigation and debridement, inspection of arthrotomy integrity, and antibiotic treatment to decrease the risk of PJI. Summary. An acute, traumatic wound dehiscence with in the first 30 days after primary TKA results in a 11% risk of infection at 2 years

Objectives. Sustained intra-articular delivery of pharmacological agents is an attractive modality but requires use of a safe carrier that would not induce cartilage damage or fibrosis. Collagen scaffolds are widely available and could be used intra-articularly, but no investigation has looked at the safety of collagen scaffolds within synovial joints. The aim of this study was to determine the safety of collagen scaffold implantation in a validated in vivo animal model of knee arthrofibrosis. Materials and Methods. A total of 96 rabbits were randomly and equally assigned to four different groups: arthrotomy alone; arthrotomy and collagen scaffold placement; contracture surgery; and contracture surgery and collagen scaffold placement. Animals were killed in equal numbers at 72 hours, two weeks, eight weeks, and 24 weeks. Joint contracture was measured, and cartilage and synovial samples underwent histological analysis. Results. Animals that underwent arthrotomy had equivalent joint contractures regardless of scaffold implantation (-13.9° versus -10.9°, equivalence limit 15°). Animals that underwent surgery to induce contracture did not demonstrate equivalent joint contractures with (41.8°) or without (53.9°) collagen scaffold implantation. Chondral damage occurred in similar rates with (11 of 48) and without (nine of 48) scaffold implantation. No significant difference in synovitis was noted between groups. Absorption of the collagen scaffold occurred within eight weeks in all animals. Conclusion. Our data suggest that intra-articular implantation of a collagen sponge does not induce synovitis or cartilage damage. Implantation in a native joint does not seem to induce contracture. Implantation of the collagen sponge in a rabbit knee model of contracture may decrease the severity of the contracture. Cite this article: J. A. Walker, T. J. Ewald, E. Lewallen, A. Van Wijnen, A. D. Hanssen, B. F. Morrey, M. E. Morrey, M. P. Abdel, J. Sanchez-Sotelo. Intra-articular implantation of collagen scaffold carriers is safe in both native and arthrofibrotic rabbit knee joints. Bone Joint Res 2016;6:162–171. DOI: 10.1302/2046-3758.63.BJR-2016-0193

Fractures of the prosthetic components after total knee arthroplasty (TKA) are rare but dangerous complications, sometimes difficult to diagnose and to manage. Aim of this study is to evaluate the incidence of component breakage and its treatment in our single institution's experience. We retrospectively review our institution registry. From 605 revision knee arthroplasties since 2000 to 2018, we found 8 cases of component breakage, of these 3 belonged to UKA, and 5 belonged to TKA. The UKA fractures were all on the metal tibial component; while 4 TKA fractures were ascribed to the liner (2 Posterior-Stabilized designs and 2 constrained designs) and only one case was on the femoral component. For every patient a revision procedure was performed, in two cases a tibial tubercle osteotomy was performed, while in one case (where the fracture was of the post cam) an arthroscopy was performed prior to the arthrotomy. All of the UKA fractures were treated with a standard revision implant. As regard the TKA, 2 liner fractures were treated with the only liner exchange, while the other 2 liner fractures and the fracture of the metallic component were treated with total knee revision. No intra- and post-operative complications were found. Component breakage after TKA is a serious complication. Its treatment, always surgical, can hide pitfalls, especially if the timing is not correct; indeed apart from the revision of one or more components, the surgeons must address any issues of management of bone defect and ligamentous stability

Aims. To describe the risk of periprosthetic joint infection (PJI) and reoperation in patients who have an acute, traumatic wound dehiscence following total knee arthroplasty (TKA). Methods. From January 2002 to December 2018, 16,134 primary TKAs were performed at a single institution. A total of 26 patients (0.1%) had a traumatic wound dehiscence within the first 30 days. Mean age was 68 years (44 to 87), 38% (n = 10) were female, and mean BMI was 34 kg/m. 2. (23 to 48). Median time to dehiscence was 13 days (interquartile range (IQR) 4 to 15). The dehiscence resulted from a fall in 22 patients and sudden flexion after staple removal in four. The arthrotomy was also disrupted in 58% (n = 15), including a complete extensor mechanism disruption in four knees. An irrigation and debridement with component retention (IDCR) was performed within 48 hours in 19 of 26 knees and two-thirds were discharged on antibiotic therapy. The mean follow-up was six years (2 to 15). The association of wound dehiscence and the risk of developing a PJI was analyzed. Results. Patients who sustained a traumatic wound dehiscence had a 6.5-fold increase in the risk of PJI (95% confidence interval (CI) 1.6 to 26.2; p = 0.008). With the small number of PJIs, no variables were found to be significant risk factors. However, there were no PJIs in any of the patients who were treated with IDCR and a course of antibiotics. Three knees required reoperation including one two-stage exchange for PJI, one repeat IDCR for PJI, and one revision for aseptic loosening of the tibial component. Conclusion. Despite having a traumatic wound dehiscence, the risk of PJI was low, but much higher than experienced in all other TKAs during the same period. We recommend urgent IDCR and a course of postoperative antibiotics to decrease the risk of PJI. A traumatic wound dehiscence increases risk of PJI by 6.5-fold. Cite this article: Bone Joint J 2021;103-B(6 Supple A):191–195

Gunshot-induced fractures of the proximal femur typically present with severe comminution and bone loss. These fractures may also be associated with local damage to soft tissue, neurovascular structures and injuries to abdominal organs. The aim was to evaluate the outcomes of civilian gunshot injuries to the proximal femur at a major trauma center in South Africa. A retrospective review of all patients who sustained gunshot-induced proximal femur fractures between January 2014 and December 2017 was performed. Patients with gunshot injuries involving the hip joint, neck of femur or pertrochanteric fractures were included. Patient demographics, clinical- treatment and outcome data were collected. Results are reported as appropriate given the distribution of continuous data or as frequencies and counts. Our study included 78 patients who sustained 79 gunshot-induced proximal femur fractures. The mean age of patients was 31 ± 112, and the majority of patients were male (93.6%). Pertrochantenteric fractures were the most common injuries encountered (73.4%). Treatment included cephalomedullary nail (60.8%), arthrotomy and internal fixation (16.4%) and interfragmentary fixation with cannulated screws (6%). One case of complete neck of femur fracture had fixation failure, which required conversion to total hip arthroplasty. The overall union rate was 69.6%, and 6.3% of patients developed a fracture-related infection in cases who completed follow-up. The study shows an acceptable union rate when managing these fractures and a low risk of infection. As challenging as they are, individual approaches for each fracture and managing each fracture according to their merits yield acceptable outcomes