Irrigation and débridement (I&D), often with exchange of modular polyethylene components, is commonly used to treat acute periprosthetic infection (PPI) following total joint arthroplasty. Two-stage revision, the “Gold Standard” for PPIs' is more invasive, requires more resources, creating controversy over recommended initial treatment of PPIs. This study seeks to determine the success rate of an “intent to treat” approach utilizing I&Ds with progression to two stage revisions as required. We retrospectively reviewed 5193 hip and knee joint arthroplasties performed over a 63 month period and identified 46 (20 female, 26 male, mean age 60) deep postoperative (within 365 days) infections that were initially managed with an “intention to treat and cure” I&D, with or without poly exchange. We investigated the overall success rate of this approach and the requirements for additional surgical procedures, as well other associated factors. 34 were managed with I&Ds only and 12 with two stage revisions as well.Background
Methods
The senior author has treated a series of patients with subtrochanteric and diaphyseal femoral stress fractures associated with long-term alendronate or other bisphosphonate usage. Several patients completely fractured their femurs prior to referral. Most patients had consulted other physicians and were referred for presumed neoplasms. All patients had been diagnosed with osteoporosis and had been treated with bisphosphonates. Their plane radiographs revealed abnormalities that are pathognomonic of bisphosphonate-associated stress fractures. However, due to the subtle nature of these new unfamiliar abnormalities, most were unrecognized as such by clinicians (including experienced ISTA member hip surgeons) and radiologists. This series is presented to illustrate this pattern of impending fracture. The authors have reviewed and will present a series (n=17) of femoral stress fractures in bisphosphonate-treated patients to illustrate the clinical and radiographic pattern of these stress fractures, and review their treatment. The most common lesion is a subtrochanteric lateral cortical thickening that in actuality is a horizontal plane “dreaded black line” of a stress fracture with surrounding proximal and distal cortical thickening of the endosteal and periosteal bone. The stress fracture line is obscured unless a near-perfect radiographic projection is obtained. The lesion is best seen with CT scans. MRI scans reveal the stress fracture lines with surrounding edema (Fig 1), which may be misinterpreted as a tumor. Without treatment, a low-impact completed fracture will likely occur. Many bisphosphonate-associated impending subtrochanteric femoral stress fractures are misdiagnosed as trochanteric bursitis, leading to subsequent displaced subtrochanteric fractures [Fig. 2 - Note subtle impending fracture lesion on right, completed fracture on left]. The clinical and subtle radiographic findings must be recognized by orthopaedic surgeons, particularly hip surgeons, to prevent these complete fractures. These fractures are preventable with internal fixation. Long-term administration of bisphosphonates can have adverse effects, and alternatives to long-term continuous dosing must be investigated to determine optimal administration regimens.
