Aims

Accurate diagnosis of chronic periprosthetic joint infection (PJI) presents a significant challenge for hip surgeons. Preoperative diagnosis is not always easy to establish, making the intraoperative decision-making process crucial in deciding between one- and two-stage revision total hip arthroplasty (THA). Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJI. We aimed to evaluate the utility of intraoperative calprotectin lateral flow immunoassay (LFI) in THA patients with suspected chronic PJI.

Pre-operative definitive diagnosis of infection in painful total hip arthroplasty (THA) is not always easy to be established, making the intra-operative decision-making process crucial in management of revision hip surgery. Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJIs.

From November 2020 to December 2022, 105 patients with painful primary THA were treated with revision THA in 3 orthopaedic departments. Pre-operatively, 23 were considered infected and treated with two-stage revision THA. The remaining 82 were likely infected according to the 2019 EBJIS criteria. The suspicion of low-grade infection was based on clinical (rest and/or night pain), laboratory (CRP, ESR, WBC – normal or slightly elevated) and radiological evaluation (loosening). Hip aspiration under CT imaging was performed in these cases and 34 of them yielded positive culture and were treated with two-stage revision. Aspiration was ineffective in the remaining 48 cases (33 negative, 15 unsuccessful attempts). Intra-operatively, calprotectin was measured with lateral flow immunoassay test in these patients. Cases with calprotectin levels ≥ 50 mg/L were treated with 2-stage revision THA; otherwise, they were considered not-infected and one-stage revision was performed. Synovial fluid and tissue samples were collected for analysis. Implants were sent for sonication fluid cultures.

Calprotectin was positive (≥ 50 mg/L) in 27 cases and negative in 21 cases. There was 1 false negative case with positive tissue cultures. Out of the 27 positive cases, 25 had positive tissue cultures and sonication. However, 2 cases with high calprotectin levels (>200 mg/L) were not infected. The false positive result was attributed to severe metallosis. Calprotectin sensitivity was 96.2%, specificity 90.9%, PPV 92.6%, NPV 95.2%, AUC 0.935.

The results of this ongoing study indicate that calprotectin seems to be a valuable tool in facilitating the intra-operative decision-making process in cases that low-grade infection is suspected and diagnosis cannot be established pre-operatively.

Aims

There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients.

Background

The degree of postoperative pain is usually moderate to severe following Total Hip Arthroplasty (THA). Comfort and lack of pain are important for optimal mobilization and earlier home discharge.

We report the long-term results of the management of neglected chronically infected total knee replacements with a two-stage re-implantation protocol. In 18 of 34 patients (53%) a resistant organism was isolated. All cases were treated by the same surgical team in a specialist centre and had a mean follow-up of 12.1 years (10 to 14). They were evaluated clinically and radiologically using the Knee Society Score (KSS) and the American Knee Society Roentgenographic scoring system, respectively. One patient died after eight years from an unrelated cause and two were lost to follow-up. Three patients (8.8%) developed a recurrent infection for which further surgery was required. The infection was eradicated successfully in 31 patients (91.1%). There was one case of aseptic loosening after 13 years. We found a significant improvement in the KSS at final follow-up (p < 0.001).

Tibial plateau fractures are common fractures which most of the times require surgery. Recovery can take several months. The aim of our study was to estimate the effect of tibial plateau fractures in quality of life of patients one year after the surgery.

During the time period 2004–2007 we treated 86 patients, with a mean age of 44 years (23–68). Fracture classification was according to Schatzker, hence, there were 9 patients with type I, 14 with type II, 20 with type III, 22 with type IV, 13 with type V and 8 with type VI. In 45 (52.3%) patients the articular surface was reduced with limited use of internal fixation and bone grafts, whereas the remaining patients had syndesmotaxis performed. In all patients stabilization was achieved with hybrid external fixators. Sixty four patients returned in one year postoperative for the study, at which time they completed the Short Form-36 (SF-36) general health surveys.

Compared to the standardized SF-36 categorical and aggregate scores there was no statistically significant difference between the healthy age-matched population and young patients with Schatzker I, II, III and IV fractures. But in 16 patients over 40 years old with Schatzker V and VI fracture, SF-36 score was lower in all categories, despite that 13 of them had full or partial return to pre-injury levels of functioning

We conclude that the age of patients and the complexity of tibial plateau fractures influence the quality of their life one year post-operative

In this study we try to evaluate the results of intramedullary nailing in the treatment of fractures of diaphysis of humerus.

During the time period of 2002 to 2006 46 patients were admitted in our clinic with fracture of the diaphysis of the humerus and 23 patients were treated surgically with intramedullary nailing. 14 patients were directly submitted to intramedullary nailing, 6 patients after unsuccessful conservative treatment and 3 patients due to nonunion after internal fixation. Average age was 51 years old. In 5 patients open reduction was applied while bone grafts were not used in any case. In all cases bone healing was obtained within 6 to 20 weeks (average 11 weeks). Final functional outcome was evaluated with Constant Score and according to it 10 patients demonstrated excellent score (> 75), 7 satisfactory (50–75) and 6 poor(< 50). Postoperative evaluation was based on clinical findings such as pain, range of motion and rehabilitation. As far as complications are concerned 2 cases with severe stiffness of the shoulder were observed and 1 case with malunion. There were no cases with non-union, sterile necrosis or neurological impairment.

Intramedullary nailing shows significant advantages such as limited damage to soft tissues, satisfactory retention of osteoporotic fractures, immobility of complex fractures and allows immediate postoperative mobilization.

The aim of this study was to evaluate the severity of pelvic fractures, to emphasize the appearance of major complications and to record the possible permanent damage of these patients.

We studied the clinical presentation of 105 patients with solid or multiple fractures during the period 2000–2007. Thirty one patients presented with acetabular fracture (5 of which showed dislocation of the corresponding hip), 52 patients presented with pelvic ring fractures and 22 patients presented with ischio-pubic and sacral fractures. The demographic data and patient history were recorded. The patients were re-evaluated in out-patient department.

There were several major complications. Pulmonary embolism occurred in 6 patients, 15 days following the fracture. One patient had a myocardial infraction, 19 days after the fracture and 1 stroke victim, 10 days following fracture. Five patients had urinary bladder rupture. Fourteen patients presented severe injury of the sciatic nerve. Three patients had a permanent urinary tract catheter and one had penile erectile dysfunction. In 13 patients there were minor complications such as numbness of limbs, groin pain and limping during gait. We needed, on average, 3.8 units of blood.

We conclude that pelvic fractures, solid or multiple, are very severe injuries. They require high level of observation due to major complications, of which increase morbidity and mortality.

Aim: To evaluate the long term results of the combined treatment of hybrid external fixator and limited internal fixation along with the advantages using pre-operative and post-operative computed tomography scan in these cases.

Material and Methods: During a period of 12 months, 16 fractures of tibial plateau, were treated in 16 patients. Fractures were classified according to Schatzker’s staging system as type II 2 cases, type III 4 cases, type IV 3 cases, type V 4 cases, type VI 3 cases. Eleven patients were men and 5 women with a mean age of 42 years old (27–67 years). In all cases pre-operatively were programmed coronal and saggital reconstructed CT-Scan, revealed the precise location and degree of articular comminution and joint depression. The principles of ligamentotaxis was used to achieve the closed indirect reduction, and limited open reduction with internal fixation was performed in 9 patients. All cases were treated with hybrid external fixators. After the removal of the plants, CT-Scan was programmed for all the cases.

Results: All patients were evaluated with a mean period of follow up 1.9 years. Healing was achieved in all 16 cases with a mean period of 16 weeks. There was no non-union. Pin tract infection occurred in two cases. Two fractures developed a malunion (1 valgus deformity and 1 anterior angular deformity). Radiographic evidence of arthritis appeared in 2 patients during follow up. CT-Scan offer us the possibility to measure precious the sinking of the tibia plateau in degrees, the condylar widening in mm, the degeneration of joint space, the varus-valgus tilt in degrees, the articular step-off in mm and the bone healing. Based to post-operative CT-Scan information we can organize a safe rehabilitation program and aloud the full bear-weight in the perfect time.

Conclusions: The use of circular external fixators obtains good stabilization allows early joint motion, protects soft tissue envelope and in combination with minimal internal fixation on achieves satisfactory reduction. It is almost impossible to measure sinking of the tibia plateau since plain radiographs do not distinguish between a local defect and depression of the condyles. The pre-operative CT-Scan assists in the pre-operative management. The post-operative CT-Scan shows important information about bone healing. Postoperative radiographs may have led to an underestimation of the degree of residual displacement. On the contrary, CT-Scan demonstrates the exact grade of articular displacement and depending on CT-Scan results one can better manage the post-operative rehabilitation.

Between November 1997 and December 2000 we performed 27 total hip replacements in 22 patients with high congenital dislocation of the hip using porous tantalum monoblock acetabular components implanted in the true acetabular bed. Clinical and radiological evaluation was performed at regular intervals for a mean of 10.2 years (8.5 to 12). The mean Harris Hip Score improved from 48.3 (15 to 65) pre-operatively to 89.5 (56 to 100) at the final follow-up. The mean Oxford Hip Score was 49.5 (35 to 59) pre-operatively and decreased to 21.2 (12 to 48) at one year and 15.2 (10 to 28) at final follow-up. Migration of the acetabular component was assessed with the EBRA software system. There was a mean migration of 0.68 mm (0.49 to 0.8) in the first year and a mean 0.89 mm (0.6 to 0.98) in the second year, after excluding one initial excessive migration. No revision was necessary for any reason, no acetabular component became loose, and no radiolucent lines were observed at the final follow-up.

The porous tantalum monoblock acetabular component is an implant offering adequate initial stability in conjunction with a modulus of elasticity and porosity close to that of cancellous bone. It favours bone ingrowth, leading to good mid-term results.

Between January 1998 and December 1998, 82 consecutive patients (86 hips) underwent total hip arthroplasty using a trabecular metal monoblock acetabular component. All patients had a clinical and radiological follow-up evaluation at six, 12 and 24 weeks, 12 months, and then annually thereafter. On the initial post-operative radiograph 25 hips had a gap between the outer surface of the component and the acetabular host bed which ranged from 1 to 5 mm. All patients were followed up clinically and radiologically for a mean of 7.3 years (7 to 7.5). The 25 hips with the 1 to 5 mm gaps were studied for component migration at two years using the Einzel-Bild-Roentgen-Analyse (EBRA) digital measurement method. At 24 weeks all the post-operative gaps were filled with bone and no acetabular component had migrated. The radiographic outcome of all 86 components showed no radiolucent lines and no evidence of lysis. No acetabular implant was revised. There were no dislocations or other complications. The bridging of the interface gaps (up to 5 mm) by the trabecular metal monoblock acetabular component indicates the strong osteoconductive, and possibly osteoinductive, properties of trabecular metal.

One hundred and twenty-nine patients who had had 153 consecutive primary total knee replacements (twenty-four bilateral procedures) between February 1988 and February 1990, with insertion of medial pivot total knee system with cementless femoral and cementless tibial component without replacement of the patella, were enrolled in a prospective study. The average age of the patients at the time of surgery was 67.4 years, the average weight was 78 kg, and the most common diagnosis was osteoarthritis (prevalence, 92.9%). Twenty-six knees had a valgus deformity, ninrty-nine had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus Six patients had a previous high tibial osteotomy, twenty-one arthroscopic debridment and thirty-two total knee athroplasty at the other knee.

One hundred and ten patients (123 knees) were followed for an adequate interval (mean, 5.1 years; range, 3.8 to 6.8 years). Thirteen patients (fifteen knees) died, and twelve patients (fifteen knees) were lost to follow-up. The mean age of the patients at the time of the index arthroplasty was seventy years (range, twenty-nine to eighty-five years). The patients were evaluated clinically and radiographically, according to the scoring system of the Knee Society, and the results on a self-administered questionnaire were used to evaluate pain, function, satisfaction, and patellofemoral symptoms. A Kaplan-Meier survivorship analysis was performed with a revision operation as the end point. Failure was defined as aseptic loosening as evidenced by progressive radiolucent lines and/or revision due to aseptic loosening or collapse.

The mean functional and clinical scores, according to the system of the Knee Society, were 85 and 93 points, respectively, at the most recent follow-up examination. The result was excellent for 103 knees, good for thirteen, fair for three, and poor for six. One revision operation was necessary because of infection. The over-all rate of patellofemoral symptoms was 6 per cent (seven knees). Non-progressive radiolucent lines were present at the cement-bone interface in 39 per cent (thirty-nine) of the ninety-nine knees that had complete radiographic follow-up. No prosthesis had loosened by the time of the most recent follow-up examination. The rate of survival of the implant was 97 per cent at six years, and the standard error of the mean was 1.6 per cent.

In the present series, total knee arthroplasties with the medial pivot modular knee system resulted in excellent relief of pain, an excellent range of motion, and restoration of function. They were also associated with a low prevalence of patellofemoral problems.

Aim:We present our experience and the results of the treatment on 36 patients with fracture of the distal end of the clavicle (Grade II type 2) by open reduction of the fracture. Method: 25 men and 11 women were treated operatively for unstable (grade II, type 2) clavicular fracture from 1999 to 2002. The average age was 27.2 years (range, eighteen to thirty- þve years). The operations were performed under general anaesthesia. By the proper procedure the clavicle and the base of the coracoid was exposed. A 3.5mm hole was drilled, and a screw is introduced through the clavicle into the coracoid. The torn ends of the coracoclavicular ligaments are tagged with sutures. Six to nine weeks postoperatively the screw was removed. Results: All patients were reviewed radiologically and clinically after on average interval of 16 months. The healing of the fractures occurs about 8 weeks later. All patients were restored to the pre Ð injury level function with no pain or abnormal motion. Conclusions: Internal þxation with Boswarth screw and repair of the coracoclavicular ligament is an effective operation for Grade II type 2 unstable clavicular fractures specially for young and athletic patients

Major Orthopaedic procedures frequently require pre-operative transfusion of allogeneic blood. A randomized study was conducted comparing the safety and efficacy of epoetin alfa in patients with hemoglobin levels > /10 to /< 13g/dl scheduled to undergo major elective orthopaedic arthroplasty.

106 patients scheduled for major elective orthopaedic surgery involving hip or knee replacement between 1998–2000. 83 Females and 23 males, mean age 73 years. The criteria were a) preoperative Hb level > /10 to /< 13, b)age50–85, c)ferritine > /50mg/dl d)good general health and normal Fe levels. The exclusion criteria included clinically significant systemic disease or laboratory chemistry abnormalities. The patients here divided in two matched groups of 53 Group A patients received 4 dose of 40.000IU Epoetin alfa on days -8,-4 prior to surgery and on days -l,-4 postoperatively. Group B patients received placebo the same days with group A. We performed 73 THR and 32TKRA11 patients received oral iron (150mg elemental iron) starting on the first day of study medication and continuing until hospital discharge.

In group A the mean Hb level was 12,55g/dl on the 8th preoperative day, 10,49g/dl on the 1st postoperative day and 10,37g/dl on the 7th postoperative day. In group B the mean Hb level was!3,36g/dl the 8th preoperative day, 1 l,06g/dl on the 1st postoperative day and 10,31g/dl on the 7th postoperative day. The percentage change in hemoglobin between the baseline measurement and the 7th postoperative day was -16,21 for group A and -22,13 for group B which was a statically significant difference (P=0,011).A mean of 1,49-+1,3 unit of allergenic blood was transfused in Epoetin alfa treated group compared with 2-+1,1 in the placebo group. The difference was statically significant (P=0,019) We had no complication.

These data suggest that the human erythropoietin, administered in 2 dose of 40.000 IU before and in 2 dose 40.000 IU after major orthopaedic operations can minimize the need for allogeneic blood transfusion.