Shoulder replacement surgery is a well-established orthopaedic procedure designed to significantly enhance patients’ quality of life. However, the prevailing preoperative admission practices within our tertiary shoulder surgery unit involve a two-stage group and save testing process, necessitating an admission on the evening before surgery. This protocol may unnecessarily prolong hospital stays without yielding substantial clinical benefits. The principal aim of our study is to assess the necessity of conducting two preoperative group and save blood tests and to evaluate the requirement for blood transfusions in shoulder arthroplasty surgeries. A secondary objective is to reduce hospital stay durations and the associated admission costs for patients undergoing shoulder arthroplasty. We conducted a retrospective observational study covering the period from 1st January 2023 to 31st August 2023, collecting data from shoulder arthroplasty procedures across three hospitals within the Aneurin Bevan University Health Board. Our analysis included 21 total shoulder replacement cases and 13 reverse shoulder replacement cases. Notably, none of the patients required postoperative blood transfusions. The mean haemoglobin drop observed was 14 g/L for total shoulder replacements and 15 g/L for reverse shoulder replacements. The mean elective admission duration was 2.4 nights for total shoulder replacements and 2 nights for reverse shoulder replacements. Our data indicated that hospital stays were extended by one night primarily due to the preoperative group and save blood tests. In light of these findings, we propose a more streamlined admission process for elective shoulder replacement surgery, eliminating the need for the evening-before-surgery group and save testing. Hospital admissions in these units incur a cost of approximately £500 per night, while the group and save blood tests cost around £30 each. This revised admission procedure is expected to optimise the use of healthcare resources and improve patient satisfaction without compromising clinical care

Guidelines for the use of preoperative blood tests for elective surgery were established. However, there is less evidence and no guidelines regarding using these tests when a young, healthy patient undergoes minor orthopaedic trauma surgery. Bloodwork is often ordered routinely, regardless of medical history or the nature of the injury. We hypothesized that unnecessary blood work is requested for younger pre-operative patients, and their results will not change peri-operative management. This practice is not a judicious use of healthcare resources. This study aimed to evaluate the frequency, type, cost, and impact on clinical decisions if standard preoperative bloodwork was completed in healthy patients requiring surgical management of a minor fracture or dislocation. After the approval of our institutional ethics board, a retrospective chart review was conducted. Inclusion criteria were patients aged 18-60 years, who had an isolated minor orthopaedic trauma requiring outpatient surgery, who were American Society of Anesthesiologists (ASA) class 1. ASA class 1 is defined as “a normal healthy patient, without any clinically important comorbidity and without a clinically significant past/present medical history.” Data records from January 1, 2016, to December 31, 2018, were extracted from a provincial database (the Analytics Data Integration, Measurement and Reporting) for five hospitals. Data including demographics, surgical treatment, type and number of blood tests ordered, and ordering physician were collected. Any abnormal test results were checked to see whether they led to a change in patient management or related to a postoperative adverse event. Independent samples t-tests and Chi-square tests were used to compare the characteristics of patients who had preoperative bloodwork versus those who did not. The cost of preoperative blood work was estimated. During these two years, 627 patients met inclusion criteria, and 27% (n=168) of these patients had bloodwork completed pre-operatively, while only 34% (n=57) of these had one or more abnormal laboratory parameters. These abnormalities were minor and did not alter clinical management or result in repeated bloodwork peri-operatively. Patients who had bloodwork were significantly older (40.2 years) compared with patients without preoperative blood work (37.8 years; p=0.03), but there was no difference in sex between those who had bloodwork (53.4% male) and those who did not (51.4% male; p=0.63). The most common blood test ordered was a complete blood count, and the most commonly abnormal result was a mildly elevated white blood cell count (19%; n= 29). The most common patients to receive bloodwork were those with ankle (34%) and distal radius (34%) fractures. The bloodwork was primarily ordered by clinical associates (26%; n=46) and emergency department physicians (22%; n=38). Without considering lab personnel, consumables, and analysis time, the cost of this bloodwork was approximately $7685, an average of $45 per patient. Pre-operative bloodwork in young, healthy, asymptomatic patients requiring outpatient surgery for minor orthopaedic trauma had no clinical significance and did not change patient management. Rigorous prospective research is warranted to establish national guidelines for appropriate pre-operative bloodwork ordering to minimize unnecessary and costly investigations

Routine post-operative bloods following all elective arthroplasty may be unnecessary. This retrospective cohort study aims to define the proportion of post-operative tests altering clinical management. Clinical coding identified all elective hip or knee joint replacement under Hawkes Bay District Health Board contract between September 2019-December 2020 (N=373). Uni-compartmental and bilateral replacements, procedures performed for cancer, and those with insufficient data were excluded. Demographics, perioperative technique, and medical complication data was collected. Pre- and post-operative blood tests were assessed. Outcome measures included clinical intervention for abnormal post-operative sodium (Na), creatinine (Cr), haemoglobin (Hb), or potassium (K) levels. A cost-benefit analysis assessed unnecessary testing. 350 patients were Included. Median age was 71 (range 34-92), with 46.9% male. Only 26 abnormal post-operative results required intervention (7.1%). 11 interventions were for low Na, 4 for low K, and 4 for elevated Cr. Only 7 patients were transfused blood products. Older age (p=0.009) and higher ASA (p=0.02) were associated with intervention of any kind. Abnormal preoperative results significantly predicted intervention for Na (p<0.05) and Cr (p<0.05). All patients requiring treatment for K used diuretic medication. Preoperative Hb level was not associated with need for transfusion. Overall, there were 1027 unnecessary investigations resulting in $18,307 excess expenditure. Our study identified that the majority of elective arthroplasty patients do not require routine postoperative blood testing. We recommend investigations for patients with preoperative electrolyte abnormality, those taking diuretics, and patients with significant blood loss noted intra-operatively. In future, a larger, randomised controlled trial would be useful to confirm these factors

Aim. The diagnosis of septic arthritis mostly relies on clinical examination, several blood parameters including white blood cell count, C-reactive protein, sedimentation, and the analysis of the joint aspiration. However, the diagnosis can be difficult when the symptoms are vague and the information obtained from laboratory might be insufficient for definitive diagnosis. This study aimed to evaluate several ratios obtained from routine blood tests for a possible use in the diagnosis of septic arthritis. Method. The adult patients who were operated in our clinic due to septic arthritis between 2014–2020 were identified and retrospectively evaluated. The patients with any blood disorders or missing file information were excluded. A total of 36 patients were found to be eligible for inclusion. The control group included 40 patients without any sign of infection who underwent total knee arthroplasty due to knee osteoarthritis. Preoperative blood tests of each patients were examined. In addition to CRP and sedimentation values, neutrophil-lymphocyte, monocyte-lymphocyte, platelet-lymphocyte, and platelet count-mean platelet volume were calculated and receiving operating characteristics (ROC) curve analysis was made to determine the sensitivity, specificity and area under curve (AUC) values of these parameters. Results. The distribution of affected joint in septic arthritis group was as follow; 22 knees, 6 hips, 4 shoulders, 2 elbows, 1 wrist and 1 ankle. The cultures of joint aspiration yielded positive result in 19 patients while the cultures were negative in 17 patients. All of the analyzed parameters were significantly different between the groups (p<0.001). ROC curve analysis results are given in detail, in Table 1 and Figure 1. The AUC value was 97.3 when only CRP and sedimentation values were used but increased to 98.6 when neutrophile/ lymphocyte ratio was added and increased to 100 when all analyzed parameters were included. Conclusions. The analyzed parameters were found to increase the overall sensitivity and specificity when used together with acute phase reactants. However, when evaluated separately, CRP and sedimentation were still found as the most valuable parameters in the diagnosis of septic arthritis. In the diagnosis of septic arthritis, 35 mm/hr cut-off value for sedimentation and 10 mg/L cut-off value for CRP were found more sensitive and specific compared to standard laboratory cut-off values of 20 mm/hr and 5 mg/L. For any tables or figures, please contact the authors directly

BACKGROUND. Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00. AIM. To investigate whether routine pretransfusion blood sampling for trauma admissions exceeds requirements. METHODS. Electronic records were used to collect pretransfusion sampling data for all adult non-elective trauma patients listed for theatre under a trauma and orthopaedics consultant between 1/1/2023-31/1/2023. Data were collected on unnecessary samples, rejected samples and total excess samples. RESULTS. 113 patients (mean age[±SD] 64.09[±19.96]) underwent 132 procedures. On average, unnecessary sampling occurred at a rate of 0.48 samples per operation, equating to a cost of £945.00/month. Samples were rejected by the laboratory at a rate of 0.25 samples per operation. Common reasons for rejection were ‘patient date of birth discrepancy’ (between sample and request form), ‘patient address discrepancy’ and ‘signature discrepancy’. Overall, total excessive sampling occurred at a rate of 0.60 samples per operation. CONCLUSION. Nearly half of trauma patients undergo unnecessary blood testing in anticipation of potential perioperative transfusion. This has implications for sustainability, financial cost and patient welfare. This signals poor understanding of WBS requirements and is an area that requires improvement

The main purpose of preoperative blood tests is to provide information to reduce the possible harm or increase the benefit to patients by altering their clinical management if necessary. This information may help clinicians assess the risk to the patient, predict postoperative complications and establish a baseline measurement for later reference. National Institute of Clinical Excellence (NICE) has issued guidelines around the need for pre-operative blood tests related to the age of the patient, comorbidities and the complexity of the procedure they will undergo. We decided to retrospectively review the pre-operative blood requests for patients under the age of 65 who were admitted at our institution over a 2 month period for open reduction and internal fixation of the ankle or tibial plateau and manipulation under anaesthesia of the lower limb. Patients were divided into 2 groups, under the age of 40 and between 40-65 years old. Patients under the age of 18 were excluded. These surgical procedures were classified as ‘intermediate complexity’. Admission clerkings of our 63 patient cohort were reviewed to ascertain if any patients had a significant co-morbidity or past medical history. The pre operative blood tests requested for each patient were audited against the NICE recommendations. None of the patients under the age of 40 had any significant comorbidites, whilst 8 patients above the age of 40 suffered with hypertension. 95% of patients had at least one blood test carried out. All patients over the age of 40 had at least one blood test. Tests requested included full blood count (91%), urea and electrolytes (91%), coagulation (66%), liver function tests (67%), group and save (69%), CRP (70%), ESR (2%), thyroid function tests (5%) and CK (2%). Only 5 patients (5%) followed the guidelines correctly. The clinical value of testing healthy individuals before an operation is debatable. The possible benefits of routine preoperative investigations include identification of unsuspected conditions that may require treatment before surgery or a change in surgical or anaesthetic management. The American Society of Anaesthesiologists has stated that ‘routine preoperative tests (i.e. tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anaesthesiologist.’. The overzealous requesting of preoperative blood tests also has a financial burden upon individual institutions. Our study also showed that some blood tests, such as inflammatory markers and thyroid function tests, were inappropriately requested. Adherence to the NICE guidelines would have resulted in a significant financial saving. This review has shown that adopting the NICE guidelines may result in a decrease in the amount of unnecessary blood tests patients undergo when they attend hospital for routine, minor or intermediate surgical procedures. If these guidelines were implemented for all surgical procedures, this would undoubtedly result in a significant financial saving for the institution and the NHS as a whole. At our institution we have implemented surgical and anaesthetic team awareness and education around these guidelines in a bid to reduce the use of unnecessary testing

Aim. Despite the availability of numerous tests, the diagnosis of periprosthetic infection (PJI) continues to be complex. Although several studies have suggested that coagulation-related markers, such as D-dimer and fibrinogen, may be promising tools in the diagnosis of prosthetic infections, their role is still controversial. The aim of this study is to evaluate the diagnostic accuracy of serum D-dimer and fibrinogen in patients with painful total knee replacement. Method. 83 patients with painful total knee replacement and suspected peri-prosthetic infection were included. All patients underwent pre-operative blood tests to evaluate inflammation indices (ESR and CRP) and serum D-Dimer and Fibrinogen levels. The diagnostic performance of the tests was assessed using the ICM definition as the gold standard. The diagnostic accuracy of the D-dimer and fibrinogen was measured by assessing sensitivity, specificity and by calculating the area under the ROC curve. Results. The definition of prosthetic infection based on the ICM criteria has made it possible to classify 40 peri-prosthetic infections and 43 aseptic failures. The mean value of fibrinogen, D-Dimer, VES and PCR observed in patients with prosthetic infection was significantly higher than in patients with aseptic failure [fibrinogen 468 mg / dl vs 331 mg / dl, p <0.001; D-Dimero 2177 ng/mL vs. 875 ng / mL, p <0.005], ESR 49 mm / hr vs 24 mm/h, p <0.001; PCR 25.5 mg /L vs 8.9 mg/L, p <0.001]. The optimal threshold value of the fibrinogen indicative of the presence of infection was 418 mg/dl, with a sensitivity of 72% and a specificity of 88%. The serum concentration of d-dimer greater than 945 ng / ml showed a sensitivity of 72.5% and a specificity of 76.7%. Conclusions. Although in this multicenter prospective study we found that serum D-dimer may have significantly higher statistical values in PJI than aseptic failures, its diagnostic power appears however limited when compared with other markers including plasma fibrinogen. Fibrinogen is regularly analyzed before surgery, the evaluation of this marker does not involve additional costs. The diagnostic accuracy appears to be similar to that of classic markers such as the level of PCR and VES. Plasma D-dimer may have a limited value in the diagnosis of PJI unlike plasma fibrinogen which has shown moderate sensitivity and excellent specificity. However, in our limited series of cases, both tests cannot be used alone in the diagnosis of infection but could contribute to the diagnosis if contextualized to ves and pcr

Background:. Early diagnosis of septic arthritis and osteomyelitis in children is essential to prevent long term sequelae. The diagnosis for these orthopaedic emergencies can be difficult and challenging especially in infants. Standard blood tests used for diagnosis have a low specificity. Procalcitonin (PCT) is significantly elevated in bacterial infections and remains low in viral infections and inflammatory conditions. Good positive predictive values for PCT have been obtained in various studies used in paediatric infections, but limited studies have examined the role in orthopaedic infections. Aims:. To introduce PCT testing in the work up of Septic Arthritis (SA) and Acute Osteomyelitis (OM) and to see if the test is useful in the diagnosis. Also to determine whether 0.2 ng/ml is a suitable cutoff level as indicated by previous studies. Method:. All children under 14 years presenting with signs and symptoms of SA/OM from 1 June 2009 to 31 June 2010 were subjected to standard blood tests with addition of PCT and compared to a control group. The definitive diagnosis was made by microbiologic examination obtained in theatre. A PCT cut-off level of 0.2 ng/mL was used. Results:. A total number of 33 patients were included in the study. Eight patients were diagnosed as OM, 4 as SA and 21 had another diagnosis. Staphylococcus aureus was the most common organism isolated in this series with no resistant organisms seen. In the SA/OM Group 11 of the 12 patients had an increased PCT level and 4 in the other diagnosis group had raised PCT. The calculated sensitivity of PCT was 92% with a confidence interval of 62–100% and the specificity was 81% with a confidence interval of 58–95%. In this study the sensitivity of CRP was 100% while the specificity 26%. The positive predictive value for PCT in this study was 73% and the negative predictive value was 94%. The accuracy for PCT in Septic Arthritis and Osteomyelitis in this study was 85%. Conclusions:. The calculated sensitivity and specificity in this study has shown that PCT testing can aid in the diagnosis of SA/OM in children using 0.2 ng/ml as cut-off level. PCT was more specific for bacterial infections in this study than CRP. Further research is needed with larger numbers to conclusively prove that this specific cut-off for PCT is significant

Aim. Shoulder prosthesis chronic infection is a rare but serious complication, likely to lead to re-interventions and poor functional outcome. Two-stage exchange surgery is considered the standard procedure by most authors. Our hypothesis was that one-stage revision procedure is a valid therapeutic option in the management of chronic infections of shoulder arthroplasty. Method. This was a mono-center retrospective cohort study. All patients who underwent, during the inclusion period, a one-stage revision procedure for a chronic infection of shoulder arthroplasty were included. All patients underwent clinical evaluation (Constant-Murray score), radiological examination (standard X-rays) and a blood test (Complete Blood Count and C-reactive protein), at a minimal one-year follow-up. Primary endpoint of this study was the infectious outcome and secondary endpoints were the functional and radiographic outcomes. Results. 16 shoulder prosthesis in 14 patients (5 females, 9 males) were included. Mean time between primary prosthesis implantation and exchange surgery was 40 months (1–145). Mean follow up was 30,5 months. The principal micro-organism involved was Propionibacterium acnes (9/16) and multiple organisms were found in 6 patients. In 14/16 (87,5%) shoulders, we found no sign of persistent infection at last follow-up. 2/16 (12,5%) shoulders were considered as still infected. On these 2 patients still infected, one refused further revision and the other was not in a good enough medical condition to undergo another procedure. 2 patients required an additional one-stage procedure for a new infection (new pathogen) after a period of two years, both free of infection at last follow-up. At last follow-up, mean Constant score was 54,8 (23–82). 7/14 (50%) patients were satisfied or very satisfied with the global fonctionnal result. Conclusions. One-stage revision procedure seems to be a valid therapeutic option in the management of infected shoulder prosthesis, as it allowed us to eradicate the infection in 87,5% patients in our serie, with a fair clinical result

Purpose. Management and outcomes of fungal periprosthetic joint infection (PJI) remain unclear due to its rarity. Although two-stage exchange arthroplasty is considered a treatment of choice for its chronic features, there is no consensus for local use of antifungal agent at the 1st stage surgery. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer in two-stage exchange arthroplasty against chronic fungal PJIs after total knee arthroplasty (TKA). Methods. Nine patients who were diagnosed and treated for chronic fungal PJIs after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, amphotericin-impregnated cement spacer was inserted for all patients. Systemic antifungal medication was used during the interval between two stage operations. Patients were followed up for more than 2 years after exchange arthroplasty and their medical records were reviewed. Results. The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, 5 to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by preoperative joint aspiration culture in 6 cases. For the other 3 cases, it was confirmed by open debridement tissue culture. All infections were caused by Candida parapsilosis except for one case which was caused by Candida pelliculosa. The average number of operations before exchange arthroplasty to solve the infection was 2.7 times (range, 1 to 5 times). Average duration of antifungal agent use confirmed by sensitivity test was 7 months (range, 4 to 15 months). Mean interval between two stage operation was 6 months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months). Conclusions. Due to its ill-defined symptoms and inconclusive blood test, fungal PJI after TKA is difficult to diagnose and has a prolonged clinical course. Two-stage exchange arthroplasty with antifungal-impregnated cement spacer is a very effective strategy with excellent outcome

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Aim. Pre-operative distinction between prosthetic joint infections (PJI) and non-infectious causes of joint failure is particularly challenging, especially in chronic situations. Guidelines propose different algorithms using numerous preoperative tests. We evaluated place of serology. Method. During a 9 month period, we included consecutive patients undergoing arthroplasty revision for a suspected chronic hip or knee infection. Serologies were sampled at the same day than the other blood tests. Results were compared with the final diagnosis, determined with peroperative bacteriological and histological results. Serology was performed using a multiplex antibody detection*. This multiplex antibody detection assay detects antibodies against Staphylococcus species, Propionibacterium acnes and Streptococcus agalactiae. Results. A total of 52 patients were enrolled. Median time from last arthroplasty was 30 months (extremes 8 months − 17 years). Median clinical signs duration was 6 months (extremes 1 – 40 months). Median CRP value was 6 mg/l (extremes 2 – 150) and sedimentation rate 12 mm (extremes 2 – 82). Diagnostic of PJI was finally retained for 17 patients and ruled out for 35. It was Staphylococcus aureus 3 times, coagulase negative staphylococci (CoNS) 5 times, P. acnes 4 times, candida sp. 2 times, Streptococcus agalactiae one time, Enterobacter cloacae one time and undetermined one time. Serology was concordant and accurate with the final diagnosis for 38 patients (27 sterile and 11 infected). For 7 of them, serology was the key parameter. In these cases, a CoNS or a P. acnes was isolated per-operatively on a single culture, out of 5 samples. Serology allowed confirming a contamination in 5 cases; and in 2 cases, even if not fulfilling the definition, it determined a PJI. In this study, serology had a global sensitivity of 65%, 77% specificity, 58% positive predictive value, and 82% negative predictive value. Serology reached 89% sensitivity with unchanged specificity in the subgroup of 11 patients with a CRP > 10 mg/l. Conclusions. We evaluated place of serology in the most complex cases of suspected chronic PJIs, with finally, only 33% cases with an infection. Modest results of serology can be explained because antigens included in the assay were not those expressed in sessile bacteria. And by persistence of a humoral response, witnesses of past infections, for patients who had past surgeries on the joint. However, simple and practical, when combined with all other parameters, serology could provide a valuable support in preoperative evaluation of chronic PJIs. * BJI InoplexTM

Aim. Peri-prosthetic joint infection is a serious and expensive complication of joint arthroplasty. Theatre discipline has infection prevention at its core with multiple studies correlating increased door opening with surgical site infection. The WHO, NICE and Philadelphia Consensus all advocate minimal theatre traffic. The Dutch Health Inspectorate consider >5 door openings per procedure excessive. Method. This prospective observational study over five weeks observed theatre door traffic during hip and knee arthroplasty within the eight laminar flow theatres at our institution. Two students attached to the department collected data. Half way through the study notices reminding people not to enter during arthroplasty were placed on the theatre doors. Results. The students observed 59 knees or hip arthroplasty 32 prior to notice's being placed on the theatre doors. The average number of door openings per case was 67 (25–130) prior to intervention and 70 (34–158) after intervention, although opening rates reduced from 1/min to 0.9/min (p=0.053). Reasons for door opening were drawing up medications, blood tests, delivery surgical equipment, general enquiries, staff breaks and “unknown” entries and exits. Conclusions. The rate of door opening was excessive and remained so after reminders were displayed. This deterioration in theatre discipline potentially has a significant negative impact on theatre hygiene and infection control. Individually wrapped components and screws along with the increasing component choice may have played some role in ‘legitimizing’ door opening. It will be challenging to reverse this behavioural trend but must be achieved

The problem of retained drain fragments is a well known but under reported complication in the literature. The authors present the case of a 66 years old male, who suffered a right distal humerus fracture luxation six years ago that was treated conservatively. He went to the emergency service with fever and right elbow purulent drainage. Physical examination showed deformity, swelling and fluctuation of the right elbow with purulent drainage through cutaneous fistula. The x-ray showed instable inveterate pseudarthrosis of the distal humerus. Leucocytosis and neutrophylia with increased CRP were presente in the blood tests and the patient started empiric treatment with Ceftiaxone IV. A MRSA was isolated in cultural exam of the exsudate, and a six weeks treatment with Vancomycin IV was iniciated. Exhaustive surgical cleaning was performed and two plastic foreing bodies (fragmented drains) were removed. At the time of discharge the patient was afebrile, with normal analytical parameters and negative culture tests. The orthopaedic surgeon should considerate the presence of a foreign body in patients with infected abcess and traumatic or surgery previous history

Acetabular fracture treatment outcomes have improved over the past two decades due to the more accurate identification of common fracture patterns, the development of more adequate surgical approaches, and the creation of improved methods for reduction and repair. However, certain cases have a distinctly lower likelihood of a favorable outcome, and in this setting primary arthroplasty as part of the open reduction and internal fixation (ORIF) may provide the best solution. Acute primary total hip arthroplasty (THA) provides primary stability and immediate pain relief, permits graded weight-bearing and early pain-free mobilization, and may also treat pre-existing hip arthritis. Removal of the femoral head improves exposure making fracture reduction and fixation easier without the need for more extensile approaches. Open reduction and internal fixation to obtain stability of the anterior and posterior columns is followed by placement of a multi-holed acetabular shell which serves as a supplementary internal fixation device. The femoral head can be used as bulk bone graft to replace and reinforce the reconstruction. These complex procedures are best undertaken by a surgical team with substantial experience with both acetabular trauma and hip arthroplasty. Despite improvements in outcomes with ORIF, THA is commonly required following failed treatment. Scarring, heterotopic ossification, bone defects, residual deformity, devitalised bone fragments and previous implants can make the procedure challenging. If the patient has undergone previous ORIF it is important to rule out low grade sepsis with appropriate blood tests (ESR + CRP) and further work-up as warranted. Surgical exposure must be carefully planned so as to be able to access all aspects of the acetabulum, including removal of hardware which may interfere with acetabular component placement. Bone stock loss, malunion and/or non-union must be evaluated with appropriate radiographs or CT scans may be required. Acetabular replacement in the face of deformity from previous trauma encompasses three main problems; bony defects, the presence of bone in places where it is not normally encountered, such as surrounding and incarcerating the femoral head, or substantially anterior or lateral to the center of the acetabulum, and movement of the acetabulum from its normal relationship to the remainder of the pelvis to a new location, such as a higher or more medialised hip center. Intraoperative landmarks may be obscured and therefore placement of reamers and the component may be confusing. THA after acetabular fracture is technically demanding and generally is accompanied by results more typical of revision than primary arthroplasty for degenerative disease

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

Almost any kind of bacteria can be involved in prosthetic joint infections (PJI). In 2014 we collected data on 3 patients presenting with hip or knee pain and radiological signs of prosthetic joint mobilization without any other clinical or biochemical suspect of infection. Interestingly, in all cases we isolated bacteria very rarely involved in human infections: Cupriavidus pauculus, Ralstonia paucula and Neisseria flavescens. Both Cupriavidus pauculus and Ralstonia paucula are Gram negative environmental bacteria which can contaminate water (tap, pool and mineral) and have been isolated from a variety of human clinical sources including blood, wounds, sputum, urine, eye, throat and peritoneal fluid, as non pathogenic flora. In such two patients we were able to cure the infection with quinolones (both strains were sensible). Neisseria species are Gram-negative bacteria included among the proteobacteria. Neisseria flavescens is often found in the upper respiratory tract and oropharynx of humans, rarely associated with infectious process (necrotizing pneumonia and empyema). In this last patient we successfully used piperacillin-tazobactam i.v. during hospitalization and shifted to amoxicillin-clavulanate per os at discharge. In conclusion, any bacteria can induce PJI: in some cases pre-operative blood tests are normal and therefore useless. We need new tests to overcome this diagnostic problem (such as alpha-defensin) and we must check on rare bacteria prolonging incubation to a more extended period of time (as in Propionebacterium acnes or Mycobacterium spp) and/or sending samples to specialized laboratories. We thank all the medical and nurse staff of Prosthetic Joint Replacement Unit of Orthopaedic Center, Humanitas Research Hospital

The infected joint arthroplasty continues to be a very challenging problem. No test has 100% diagnostic accuracy for PPI and the treating surgeon must correlate the clinical and radiographic presentation with a combination of blood tests, synovial fluid analysis, microbiological and histopathological evaluation of periprosthetic tissue and intra-operative inspection to reach a definitive diagnosis. Diagnosis should begin with a high index of suspicion for new onset of pain or symptoms in well-functioning joints. Plain radiographs may identify osteolysis or early signs of implant failure and should be promptly investigated further for PPI. Peripheral blood ESR and CRP remain the most widely used next step for the diagnosis of PPI. Both these tests are widely available, inexpensive, and have a rapid turnaround time in laboratories. The results should be interpreted with caution due to their relative lack of specificity. The sensitivity and specificity values for CRP are approximately 88 and 74%, respectively; while that of ESR is slightly lower at 75 and 70%, respectively. The combined ESR and CRP tests are 96% sensitive for ruling out PPI but the specificity of this combination is as low as 56%. Advanced imaging modalities may be used as a part of the diagnostic algorithm. However, they require expert interpretation and are limited by availability and high costs. When available they have high sensitivity and specificity but their routine use is not recommended and indications have to be individualised in the light of clinical presentation. In the presence of high clinical suspicion, the clinician should plan synovial fluid analysis. This provides a synovial fluid white cell count with differential cell count, specimen for culture and possibility of analyzing other synovial fluid markers. It is important to note that failed metal-on-metal hip arthroplasties can give a falsely elevated synovial fluid cell count when using automated cell counters. This can be overcome by manually counting cell numbers. Synovial fluid should be directly into blood culture bottles, and antibiotics should be withheld at least 2 weeks prior to aspiration, whenever possible. Cultures also help establish the organism, virulence and sensitivities that help plan subsequent treatment algorithm. Periprosthetic tissue biopsy provides valuable information in microbiological diagnosis and workup of PPI. Routine use of gram staining is not recommended due to poor sensitivity. However, frozen section may have some role especially when performed by a skilled pathologist. Tissue culture remains the gold standard for diagnosis despite false-positive and false-negative results. Whenever possible multiple samples should be obtained to aid interpretation. A threshold of 2 to 3 positive specimens yielding indistinguishable microorganisms has been recommended to improve sensitivity. Acute inflammation, evidenced by neutrophilic infiltrate on fixed or frozen tissue, is suggestive of PPI and is defined as the presence of at least 5 neutrophils per high-powered field, in at least 5 separate microscopic fields. Sonication of removed prosthetic components is used to dislodge the biofilm and the associated bacteria from the surface of the implant. The fluid surrounding the implant can be used for culture or analysis. PCR testing: Synovial fluid aspirate, periprosthetic tissue or sonicate fluid may be subject to molecular diagnosis to amplify genetic material and improve microbiological diagnosis of PPI. This technique has shown increased sensitivity in patients who had received antibiotics within 14 days before implant removal. Results have to carefully interpreted with due consideration for possibility of false positive results

Pain following total hip arthroplasty is a relatively rare event. Several series place the incidence of some degree of pain post THA at approximately 5%. A systematic approach to determining etiology will direct treatment. Hip pain can be categorised as:. Extrinsic to the Hip. –. Spine +/− radiculopathy. –. Vascular disease. –. Metabolic (Paget's). –. Malignancy. Intrinsic to the Hip. Intracapsular/Implant. Loosening. Sepsis. Prosthetic failure. Osteolysis. Instability. Thigh pain. Stem tip pain. Hypersensitivity/ALVAL. Extracapsular. Iliopsoas tendonitis. Snapping Hip. Trochanter problems (bursitis). Heterotopic ossification. A full history and appropriate physical exam will direct the clinician. The use of routine radiographs, blood tests, and special tests (i.e., blood metal ions, advanced imaging techniques) will be discussed I detail

The infected joint arthroplasty continues to be a very challenging problem. No test has 100% diagnostic accuracy for PPI and the treating surgeon must correlate the clinical and radiographic presentation with a combination of blood tests, synovial fluid analysis, microbiological and histopathological evaluation of periprosthetic tissue and intra-operative inspection to reach a definitive diagnosis. Diagnosis should begin with a high index of suspicion for new onset of pain or symptoms in well-functioning joints. Plain radiographs may identify osteolysis or early signs of implant failure and should be promptly investigated further for PPI. Peripheral blood ESR and CRP remain the most widely used next step for the diagnosis of PPI. Both these tests are widely available, inexpensive, and have a rapid turnaround time in laboratories. The results should be interpreted with caution due to their relative lack of specificity. The sensitivity and specificity values for CRP are approximately 88 and 74%, respectively; while that of ESR is slightly lower at 75 and 70%, respectively. The combined ESR and CRP tests are 96% sensitive for ruling out PPI but the specificity of this combination is as low as 56%. Advanced imaging modalities may be used as a part of the diagnostic algorithm. However, they require expert interpretation and are limited by availability and high costs. When available they have high sensitivity and specificity but their routine use is not recommended and indications have to be individualised in the light of clinical presentation. In the presence of high clinical suspicion, the clinician should plan synovial fluid analysis. This provides a synovial fluid white cell count with differential cell count, specimen for culture and possibility of analyzing other synovial fluid markers. It is important to note that failed metal-on-metal hip arthroplasties can give a falsely elevated synovial fluid cell count when using automated cell counters. This can be overcome by manually counting cell numbers. Synovial fluid should be directly into blood culture bottles, and antibiotics should be withheld at least 2 weeks prior to aspiration, whenever possible. Cultures also help establish the organism, virulence and sensitivities that help plan subsequent treatment algorithm. Periprosthetic tissue biopsy provides valuable information in microbiological diagnosis and workup of PPI. Routine use of gram staining is not recommended due to poor sensitivity. However, frozen section may have some role especially when performed by a skilled pathologist. Tissue culture remains the gold standard for diagnosis despite false-positive and false-negative results. Whenever possible multiple samples should be obtained to aid interpretation. A threshold of 2 to 3 positive specimens yielding indistinguishable microorganisms has been recommended to improve sensitivity. Acute inflammation, evidenced by neutrophilic infiltrate on fixed or frozen tissue, is suggestive of PPI and is defined as the presence of at least 5 neutrophils per high-powered field, in at least 5 separate microscopic fields. Sonication of removed prosthetic components is used to dislodge the biofilm and the associated bacteria from the surface of the implant. The fluid surrounding the implant can be used for culture or analysis. PCR testing: Synovial fluid aspirate, periprosthetic tissue or sonicate fluid may be subject to molecular diagnosis to amplify genetic material and improve microbiological diagnosis of PPI. This technique has shown increased sensitivity in patients who had received antibiotics within 14 days before implant removal. Results have to carefully interpreted with due consideration for possibility of false positive results