Aim

In 10% of the presumed aseptic hip or knee revisions, a low-grade infection is unexpectedly diagnosed based on the tissue samples taken during revision. Extended antimicrobial prophylaxis can possibly reduce the failure rate in cases of unexpected PJI, because the prophylaxis can be considered as early empiric treatment. In this randomized controlled study we analysed whether extended antimicrobial prophylaxis compared to a single dose is beneficial to improve the outcome of treatment in unexpected PJI in revision arthroplasty.

Aim

To date, the value of culture results after a debridement, antibiotics and implant retention (DAIR) for early (suspected) prosthetic joint infection (PJI) as risk indicators in terms of prosthesis retention is not clear. At one year follow-up, the relative risk of prosthesis removal was determined for culture-positive and culture-negative DAIRs after primary total hip or knee arthroplasty. The secondary aim was to explore differences in patient characteristics, infection characteristics and outcomes between these two groups.

Aim

Periprosthetic joint infection (PJI) is a feared complication of total joint arthroplasty of hip (THA) or knee (TKA). Debridement, antibiotic treatment, and implant retention (DAIR) is an effective treatment of early PJI. In the Netherlands, cefazolin resistance in early PJI after primary arthroplasty is low. Little is known about causative micro-organisms and resistance patterns in PJI after revision arthroplasty. No recommendations for empirical treatment are described in the current guidelines. The aim of this study is to describe the characteristics of PJI after revision arthroplasty and to evaluate whether the used empirical treatment regimens are adequate, based on microbiology data.

Aim

National Joint Replacement Registries, which are important sources for periprosthetic joint infection (PJI) data, report an average PJI incidence ranging from 0.5 to 2.0%. Unfortunately, national registries including the Dutch Arthroplasty Register (LROI), are not specifically designed to register PJI. In the Netherlands, the LROI is a nationwide population-based registry with an overall completeness of more than 95%.³ To ensure usability and reliability of PJI data from the LROI, it is important to evaluate the quality and completeness of these data. From 2013 onwards, eight hospitals in the South-East of the Netherlands, collected their PJI data in a detailed regional infection cohort (RIC), specifically designed for this purpose. This study aimed to determine the accuracy and completeness of PJI registration (hip and knee arthroplasty) in the LROI, by comparing the LROI with the RIC.

Total hip arthroplasty (THA) in patients under 30 years remains a challenge. The long-term survival data are often disappointing. In our institution, we have always used cemented components in all patients under 30 years, combined with acetabular impaction bone grafting (IBG), if necessary.

We reviewed 139 consecutive patients (180 hips) treated between 1986 to 2014. Mean age at time of surgery was 24 (13–30.0) years. Acetabular IBG was applied in 127 (71%) cases. AAOS cavitary defect was seen in 26 (14%) cases, a AAOS segmental defect in 51 (28%) and a combination in 17 (9%).

The mean preoperative HHS improved from 47 (20–81) to 87 (28–100) at review. During follow-up 26 hips have been revised (23 cups and 11 stems). Indications for revision were aseptic loosening (n=15), septic loosening (n=5), recurrent dislocation (n=3), wear (n=1), and stem fracture (n=1).

The 10-year Kaplan-Meier survival of any component with endpoint revision for any reason was 87% (95% CI 79%–92%) and for aseptic loosening 92% (84%–96%). The 15-year survival of any component with revision for any reason as the endpoint was 77% (65%–86%) and for aseptic loosening 84% (71%–92%).

Cemented THA and, if needed with impaction bone grafting, in patients under 30 years provides satisfying long-term results up to 15 years after surgery. Probably this biological approach with IBG may facilitate the inevitable revisions in the future in these young patients because of more bone stock.

Prosthetic joint infection (PJI) is a severe complication of prosthetic joint implantation, with an estimated incidence of 2.18%. Most frequently used treatment strategy for PJI is a two-stage revision procedure. However there are specific patients with a new or persisting infection after primary or revision surgery where further surgical treatment is not attractive. This may be because of medical or local surgical conditions, or patient's refusal to undergo (further) surgical therapy. For these patients suppressive antibiotic therapy (SAT) may be an alternative treatment.

The aim of this study is to describe the clinical and radiological outcome of patients with a PJI of a hip arthroplasty, treated with SAT.

Twenty-four patients with a hip arthroplasty treated with suppressive antibiotic therapy for PJI between January 1, 2008 and December 31, 2013 were included. All patients had a proven prosthetic joint infection, either by ≥2 intraoperative cultures or joint aspiration. SAT was defined as treatment with antibiotic therapy for more than three months. Most used antibiotics were doxycycline in 15 patients and cotrimoxazole in six patients.

Patients were supposed to have a successful outcome when their prosthesis remained in situ and they had no relapse or new infection.

Suppressive antibiotic therapy was considered successful in 15 (62.5%) patients with a mean follow-up of 20.6 months. Two patients (8.3%) had to stop the antibiotic therapy due to adverse effects.

The mean duration of the SAT was 20.4 months (range 0.92–92.65 months).

Mean modified Oxford hip score of the successfully treated patients at the latest follow up was 35 (range 16–49) and mean Harris hip score 71 (range 40–93). The mean visual analogue scale (VAS) was 16 (range 0–70) in rest, 32 (range 0–85) during exercise and 65 (range 10–100) for satisfaction.

Of the 9 patients with an unsuccessful outcome, there was a radiological loosening of the cup in 4 patients. In the group of 15 patients that were considered successful, 2 patients had a radiological loosening of the cup and one patient loosening of the stem.

Suppressive antibiotic therapy can be an attractive alternative treatment in selected patients with a prosthetic joint infection of a hip arthroplasty who cannot or will not undergo (further) surgical therapy.

Further research with a larger number of patients is required. Also the optimal dosage and duration of suppressive antibiotic therapy and possible resistance to the antibiotic therapy is unknown.

This retrospective study evaluates the outcome of patients with a late infection of a cemented total hip arthroplasty (THA) treated with two-stage revision with retention of the original well-fixed femoral cement mantle.

Operation reports of all two stage revision performed in our clinic between 2009 and 2013 were reviewed (249 patients). Patients in which femoral cement mantle was retained during surgery were included (10 patients). The average age at the first stage revision procedure was 61.5 years (range 38–80). The mean follow-up period was 26 months (range 5 to 54 months). Clinical, laboratory, and radiological outcomes were evaluated.

Successful treatment of periprosthetic joint infection (PJI) was achieved in six out of 10 patients; four patients showed no signs of infection during follow-up. Two of these patients received three months of antibiotic treatment after second stage, because of positive cultures at second stage. The other two successfully treated patients showed recurrence of PJI one week after second stage. Debridement with retention of prosthesis (DAIR) was performed. Newly cultured microorganisms were successfully treated with 3 months of antibiotics.

The other four patients were considered to be failures; in three patients, the femoral cement mantle was removed after the first stage due to recurrent infection. The other failure showed a recurrent PJI after second stage. Despite DAIR and three months of antibiotic treatment, this patient is treated with suppressive antibiotics until latest follow-up.

Based on this study, results in managing an infected THA with cement-within-cement revision are disappointing. Therefore, more research is required to determine which patients are appropriate for cement-within-cement revision.

Introduction

The different types of treatment for osteonecrosis of the femoral head have not led to a consensus about which treatment is best for the different stages. Particularly in the later stages of osteonecrosis, the disease still progresses to destruction of the femoral dome. The purpose of our study was to check the outcome of bone impaction grafting used for the head-preserving treatment of severe femoral head osteonecrosis. In order to preserve the femoral head, the sphericity and mechanical properties of the femoral dome must be contained and further collapse prevented.

Introduction: Results of primary total hip arthoplasty (THA) for osteonecrosis of the femoral head are improving with newer cementation techniques and components. However not much is known about results of THA after an initial femoral head preserving procedure. The purpose of this study is to compare the complications and the clinical and radiological outcome of THA after failed transtrochanteric rotational osteotomy (Sugioka technique) (THA after TRO) and THA after failed bone impaction grafting (THA after BIG) for osteonecrosis of the femoral head.

Methods: In this retrospective comparative study, sixteen cemented THA after TRO and seventeen cemented THA after BIG were performed from 1994 to 2004. These groups were compared at a minimum follow-up time of two years. The average age at time of THA was 35 years in the THA after TRO group and 39 in the THA after BIG group.

Results: In THA after TRO, perioperative blood loss was significantly increased, operation time was significantly longer, and hospital admission was significantly longer compared with THA after BIG. In THA after TRO, 4 patients required re-operations because of infection (2) and dislocations (2) compared to one re-operation in THA after BIG (revision of acetabular cup). A radiolucency of the cup without re-operation was observed in one patient in the THA after TRO group. The average Harris Hip Score (HHS) in THA after TRO improved from 52 points prior to THA to 89 points at time of review and in the THA after BIG group from 42 to 91 points with a higher rise of HHS per year of follow-up.

Discussion: We conclude that a THA after TRO was technically more demanding with a higher rate of complications and re-operations compared to THA after BIG. However, because of the small groups, no significant difference in outcome was demonstrated.

Introduction: Osteonecrosis of the distal femur produces a segment of dead bone in the weight-bearing portion of the femoral condyle, frequently associated with subchondral fracture and collapse, and eventually resulting in secondary osteoarthritis.

Materials and Methods: We developed a new surgical technique; the osteonecrotic lesion was removed and impacted bone grafts were used to regain sphericity and prevent collapse. In this prospective one surgeon study, we included 9 consecutive knees (6 patients) with extensive steroid-associated osteonecrotic lesions of the femoral condyles. A new staging system was developed that includes location and quantification of the osteonecrotic lesion.

Results: Six knees showed a preoperative collapse. The mean age of the patients was 31 years (range, 16–47 years). At a mean follow up of 51 months (range, 29–93 months), no conversion to total knee arthroplasty was performed. The objective Knee Society Score improved from 63 to 89 points. The functional Knee Society Score improved from 19 to 81 points. At follow up, there was no progression of collapse observed and only 3 knees showed slight signs of osteoarthritis. The clinical success rate was 75%, and 78% were radiologically successful.

Discussion: This method is attractive as a salvage procedure, is relatively simple and quick and does not interfere with an eventual future total knee arthroplasty.

Introduction: The transtrochanteric rotational osteotomy according to Sugioka is used to preserve the femoral head and to prevent secondary osteoarthritis in young patients with osteonecrosis of the femoral head. Several Japanese studies showed favorable results, but European and American studies were disappointing. However, many factors could be responsible for this outcome including race dependent differences and the followed post-operative rehabilitation program. The purpose of our study was to investigate this transtrochanteric rotational osteotomy in Caucasian patients with osteonecrosis in which we followed the original method of Sugioka as close as possible including a 6 months period of non-weightbearing.

Methods: In a single surgeon prospective study we included 26 hips in 22 consecutive patients who were followed for 8.7 years (range, 6.6–10 years) after surgery. The average age at time of surgery was thirty-two years (range, 22–49 years). No patient was lost to follow up. According the ARCO classification, 7 hips were in stage 2, 2 hips in stage 3 early and 17 hips in stage 3 late.

Results: At review 17 hips had been converted to total hip arthroplasty; 2 for infection, 3 for failed osteosyntheses or non-healing of the osteotomy, 12 for progressive osteoarthritis. Taking conversion to total hip arthroplasty for any reason or Harris Hip Score below 70 as endpoint, the clinical survival rate using the Kaplan-Meier analysis was 56 per cent after 7 years (95% C.I. 36–76%). Patients with a higher age at time of surgery had a tendency to a lower clinical survival rate. Taking conversion to total hip arthroplasty, progression of collapse of the femoral head or progression of osteoarthritis of the femoral head as endpoint, the radiological survival rate using the Kaplan-Meier analysis was 89 per cent after 1 year (95% C.I. 68–100%) for patients without pre-operative collapse of the femoral head. For patients with a pre-operative collapse of the femoral head, this survival rate was 35 per cent after 1 year (95% C.I. 13–58%).

Conclusion: Even after excluding the failures due to problems with osteosynthesis the results were not satisfying and the osteoarthritic process was not delayed in an effective way. Based on our results we cannot recommend this technique as an alternative for total hip arthroplasty in Caucasians.

Introduction: Even in extensive osteonecrosis of the femoral head, a head-preserving method is preferable in younger patients. This study presents the results of bone impaction grafting for osteonecrosis of the femoral head.

Materials and Methods: After a core biopsy and removal of the osteonecrotic area, impacted morsellized bone allografts were used to fill the femoral head to regain sphericity, and to prevent collapse. This prospective, single-surgeon study included 28 consecutive hips in 27 patients with extensive osteonecrotic lesions (ARCO classification Stage 2 (11 hips), Stage 3 (14 hips), and Stage 4 (three hips). Fourteen hips had preoperative collapse. The mean age of the patients was 33 years (range, 15–55 years).

Results: At a mean follow-up of 42 months (range, 24–119 months), eight hips (29%) had been converted to a total hip arthroplasty. Of the 20 reconstructions that were in situ, 18 were clinically successful (90%) and 70% were radiologically successful. Patients who were younger than 30 years at surgery had a significantly better radiologic outcome, even when compared to heads with higher stages of osteonecrosis. Patients with preoperative collapse or a continuous use of corticosteroids had disappointing results.

Discussion: This method is attractive as a salvage procedure for osteonecrosis of the femoral head. It is relatively simple and quick to perform, and it does not intervene with an eventual future hip arthroplasty.