Aims. The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell
Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier. A prospective series of 100 patients with Cierny-Mader Types III and IV chronic ostemyelitis, affecting 105 bones, were treated with a single-stage procedure including debridement, deep tissue sampling, local and systemic antibiotics, stabilization, and immediate skin closure. Chronic osteomyelitis was confirmed using strict diagnostic criteria. The mean follow-up was 6.05 years (4.2 to 8.4).Aims
Methods
Nanotechnology is the study, production and controlled
manipulation of materials with a grain size <
100 nm. At this
level, the laws of classical mechanics fall away and those of quantum
mechanics take over, resulting in unique behaviour of matter in
terms of melting point, conductivity and reactivity. Additionally,
and likely more significant, as grain size decreases, the ratio
of surface area to
We describe our medium-term results for the management of chronic osteomyelitis in long bones using the Lautenbach procedure. Seventeen consecutive patients (18 segments) were treated prospectively. Osteomyelitis had been present for a mean of 12.5 years (1 to 31). A discharging sinus was present in all cases. Nine of the associated fractures had failed to unite and a further two needed correction of malunion. The Lautenbach procedure involves debridement, intramedullary reaming and the insertion of double-lumen tubes to establish both a local antibiotic delivery system and cavity analysis for
We prospectively audited 79 patients undergoing primary knee or hip arthroplasty (38 knees, 41 hips) and found that 66% (58% of knees, 73% of hips) had at least one unit of blood transfused postoperatively, with a mean transfusion requirement of 1.3 units per patient (1.1 for knees, 0 to 6; 1.5 for hips, 0 to 4). We then established a new protocol for postoperative blood transfusion. This requires the calculation of the maximum allowable blood loss (MABL) that each individual patient can safely lose based upon their weight and preoperative haematocrit. The total blood loss up to this
This study aimed to assess the performance of an automated multiplex polymerase chain reaction (mPCR) technique for rapid diagnosis of native joint septic arthritis Consecutive patients with suspected septic arthritis undergoing aseptic diagnostic joint aspiration were included. The aspirate was used for analysis by mPCR and conventional microbiological analysis. A joint was classed as septic according to modified Newman criteria. Based on receiver operating characteristic (ROC) analysis, the area under the ROC curve (AUC) values of the mPCR and the synovial fluid culture were compared using the z-test. A total of 72 out of 76 consecutive patients (33 women, 39 men; mean age 64 years (22 to 92)) with suspected septic arthritis were included in this study.Aims
Patients and Methods
Calcium sulphate (CaSO4) is a resorbable material
that can be used simultaneously as filler of a dead space and as
a carrier for the local application of antibiotics. Our aim was
to describe the systemic exposure and the wound fluid concentrations
of vancomycin in patients treated with vancomycin-loaded CaSO4 as
an adjunct to the routine therapy of bone and joint infections. A total of 680 post-operative blood and 233 wound fluid samples
were available for analysis from 94 implantations performed in 87
patients for various infective indications. Up to 6 g of vancomycin
were used. Non-compartmental pharmacokinetic analysis was performed
on the data from 37 patients treated for an infection of the hip.Aims
Patients and Methods
Chronic osteomyelitis may recur if dead space management, after
excision of infected bone, is inadequate. This study describes the
results of a strategy for the management of deep bone infection
and evaluates a new antibiotic-loaded biocomposite in the eradication
of infection from bone defects. We report a prospective study of 100 patients with chronic osteomyelitis,
in 105 bones. Osteomyelitis followed injury or surgery in 81 patients.
Nine had concomitant septic arthritis. 80 patients had comorbidities
(Cierny-Mader (C-M) Class B hosts). Ten had infected nonunions. All patients were treated by a multidisciplinary team with a
single-stage protocol including debridement, multiple sampling,
culture-specific systemic antibiotics, stabilisation, dead space
filling with the biocomposite and primary skin closure. Aims
Patients and Methods
The purpose of this article is to provide the
reader with a seven-step checklist that could help in minimising
the risk of PJI. The check list includes strategies that can be
implemented pre-operatively such as medical optimisation, and reduction
of the bioburden by effective skin preparation or actions taking
during surgery such as administration of timely and appropriate
antibiotics or blood conservation, and finally implementation of
post-operative protocols such as efforts to minimise wound drainage
and haematoma formation. Cite this article:
Bactericidal levels of antibiotics are difficult
to achieve in infected total joint arthroplasty when intravenous antibiotics
or antibiotic-loaded cement spacers are used, but intra-articular
(IA) delivery of antibiotics has been effective in several studies.
This paper describes a protocol for IA delivery of antibiotics in
infected knee arthroplasty, and summarises the results of a pharmacokinetic
study and two clinical follow-up studies of especially difficult
groups: methicillin-resistant Cite this article:
We report our experience using a biodegradable
calcium sulphate antibiotic carrier containing tobramycin in the surgical
management of patients with chronic osteomyelitis. The patients
were reviewed to determine the rate of recurrent infection, the
filling of bony defects, and any problems with wound healing. A
total of 193 patients (195 cases) with a mean age of 46.1 years
(16.1 to 82.0) underwent surgery. According to the Cierny–Mader
classification of osteomyelitis there were 12 type I, 1 type II,
144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3
to 7.1) with recurrent infection occurring in 18 cases (9.2%) at
a mean of 10.3 months post-operatively (1 to 25.0). After further
treatment the infection resolved in 191 cases (97.9%). Prolonged
wound ooze (longer than two weeks post-operatively) occurred in
30 cases (15.4%) in which there were no recurrent infection. Radiographic
assessment at final follow-up showed no filling of the defect with
bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling
in eight (4.4%). A fracture occurred in nine (4.6%) of the treated
osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after
operation. We conclude that Osteoset T is helpful in the management of patients
with chronic osteomyelitis, but the filling of the defect in bone
is variable. Prolonged wound ooze is usually self-limiting and not
associated with recurrent infection. Cite this article:
Treatment for osteoarthritis (OA) has traditionally
focused on joint replacement for end-stage disease. An increasing number
of surgical and pharmaceutical strategies for disease prevention
have now been proposed. However, these require the ability to identify
OA at a stage when it is potentially reversible, and detect small
changes in cartilage structure and function to enable treatment
efficacy to be evaluated within an acceptable timeframe. This has
not been possible using conventional imaging techniques but recent
advances in musculoskeletal imaging have been significant. In this
review we discuss the role of different imaging modalities in the
diagnosis of the earliest changes of OA. The increasing number of
MRI sequences that are able to non-invasively detect biochemical
changes in cartilage that precede structural damage may offer a
great advance in the diagnosis and treatment of this debilitating
condition. Cite this article:
This paper offers a summary of the ethical guide
for the European orthopaedic community; the full report will be
published in the EFORT Journal. Cite this article:
Clinical, haematological or economic benefits of post-operative blood salvage with autologous blood re-transfusion have yet to be clearly demonstrated for primary total hip replacement. We performed a prospective randomised study to analyse differences in postoperative haemoglobin levels and homologous blood requirements in two groups of patients undergoing primary total hip replacement. A series of 158 patients was studied. In one group two vacuum drains were used and in the other the ABTrans autologous retransfusion system. A total of 58 patients (76%) in the re-transfusion group received autologous blood. There was no significant difference in the mean post-operative haemoglobin levels in the two groups. There were, however, significantly fewer patients with post-operative haemoglobin values less than 9.0 g/dl and significantly fewer patients who required transfusion of homologous blood in the re-transfusion group. There was also a small overall cost saving in this group.
Periosteum is important for bone homoeostasis
through the release of bone morphogenetic proteins (BMPs) and their
effect on osteoprogenitor cells. Smoking has an adverse effect on
fracture healing and bone regeneration. The aim of this study was
to evaluate the effect of smoking on the expression of the BMPs
of human periosteum. Real-time polymerase chain reaction was performed
for BMP-2,-4,-6,-7 gene expression in periosteal samples obtained from
45 fractured bones (19 smokers, 26 non-smokers) and 60 non-fractured
bones (21 smokers, 39 non-smokers). A hierarchical model of BMP
gene expression (BMP-2 >
BMP-6 >
BMP-4 >
BMP-7) was demonstrated
in all samples. When smokers and non-smokers were compared, a remarkable
reduction in the gene expression of BMP-2, -4 and -6 was noticed
in smokers. The comparison of fracture and non-fracture groups demonstrated
a higher gene expression of BMP-2, -4 and -7 in the non-fracture
samples. Within the subgroups (fracture and non-fracture), BMP gene
expression in smokers was either lower but without statistical significance
in the majority of BMPs, or similar to that in non-smokers with
regard to BMP-4 in fracture and BMP-7 in non-fracture samples. In
smokers, BMP gene expression of human periosteum was reduced, demonstrating
the effect of smoking at the molecular level by reduction of mRNA
transcription of periosteal BMPs. Among the BMPs studied, BMP-2
gene expression was significantly
Surgeons need to be able to measure angles and distances in three dimensions in the planning and assessment of knee replacement. Computed tomography (CT) offers the accuracy needed but involves greater radiation exposure to patients than traditional long-leg standing radiographs, which give very little information outside the plane of the image. There is considerable variation in CT radiation doses between research centres, scanning protocols and individual scanners, and ethics committees are rightly demanding more consistency in this area. By refining the CT scanning protocol we have reduced the effective radiation dose received by the patient down to the equivalent of one long-leg standing radiograph. Because of this, it will be more acceptable to obtain the three-dimensional data set produced by CT scanning. Surgeons will be able to document the impact of implant position on outcome with greater precision.
We performed a systematic review and meta-analysis
to compare the efficacy of intermittent mechanical compression combined
with pharmacological thromboprophylaxis, against either mechanical
compression or pharmacological prophylaxis in preventing deep-vein
thrombosis (DVT) and pulmonary embolism in patients undergoing hip
or knee replacement. A total of six randomised controlled trials,
evaluating a total of 1399 patients, were identified. In knee arthroplasty,
the rate of DVT was reduced from 18.7% with anticoagulation alone
to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03;
number needed to treat: seven). There was moderate, albeit non-significant,
heterogeneity (I2 = 42%). In hip replacement, there was
a non-significant reduction in DVT from 8.7% with mechanical compression
alone to 7.2% with additional pharmacological prophylaxis (RR 0.84)
and a significant reduction in DVT from 9.7% with anticoagulation
alone to 0.9% with additional mechanical compression (RR 0.17, p
<
0.001; number needed to treat: 12), with no heterogeneity (I2 =
0%). The included studies had insufficient power to demonstrate
an effect on pulmonary embolism. We conclude that the addition of intermittent mechanical leg
compression augments the efficacy of anticoagulation in preventing
DVT in patients undergoing both knee and hip replacement. Further
research on the role of combined modalities in thromboprophylaxis
in joint replacement and in other high-risk situations, such as fracture
of the hip, is warranted.
The most frequent cause of failure after total
hip replacement in all reported arthroplasty registries is peri-prosthetic
osteolysis. Osteolysis is an active biological process initiated
in response to wear debris. The eventual response to this process
is the activation of macrophages and loss of bone. Activation of macrophages initiates a complex biological cascade
resulting in the final common pathway of an increase in osteolytic
activity. The biological initiators, mechanisms for and regulation
of this process are beginning to be understood. This article explores current
concepts in the causes of, and underlying biological mechanism resulting
in peri-prosthetic osteolysis, reviewing the current basic science
and clinical literature surrounding the topic.
Using inaccurate quotations can propagate misleading
information, which might affect the management of patients. The
aim of this study was to determine the predictors of quotation inaccuracy
in the peer-reviewed orthopaedic literature related to the scaphoid.
We randomly selected 100 papers from ten orthopaedic journals. All references
were retrieved in full text when available or otherwise excluded.
Two observers independently rated all quotations from the selected
papers by comparing the claims made by the authors with the data
and expressed opinions of the reference source. A statistical analysis
determined which article-related factors were predictors of quotation
inaccuracy. The mean total inaccuracy rate of the 3840 verified
quotes was 7.6%. There was no correlation between the rate of inaccuracy
and the impact factor of the journal. Multivariable analysis identified
the journal and the type of study (clinical, biomechanical, methodological,
case report or review) as important predictors of the total quotation
inaccuracy rate. We concluded that inaccurate quotations in the peer-reviewed
orthopaedic literature related to the scaphoid were common and slightly
more so for certain journals and certain study types. Authors, reviewers
and editorial staff play an important role in reducing this inaccuracy.
Between November 1994 and June 1999, 35 patients referred to our Problem Fracture Service with chronic diaphyseal osteomyelitis were treated using a closed double-lumen suction irrigation system after reaming and arthroscopic debridement of the intramedullary canal. This is a modified system based on that of Lautenbach. Between June and July 2007 the patients were reviewed by postal questionnaire and telephone and from the case notes. At a mean follow-up of 101 months (2 to 150), 26 had no evidence of recurrence and four had died from unrelated causes with no evidence of recurrent infection. One had been lost to follow-up at two months and was therefore excluded. Four had persisting problems with sinus discharge and one had his limb amputated for recurrent metaplastic change. Our results represent a clearance of infection of 85.3% (29 of 34), with recurrence in 11.8% (4 of 34). They are comparable to the results of the Papineau and Belfast techniques, but with considerably less surgical insult to the patient.