Charcot neuroarthropathy is a rare but serious complication of diabetes, causing progressive destruction of the bones and joints of the foot leading to deformity, altered biomechanics and an increased risk of ulceration.

Management is complicated by a lack of consensus on diagnostic criteria and an incomplete understanding of the pathogenesis. In this review, we consider recent insights into the development of Charcot neuroarthropathy.

It is likely to be dependent on several interrelated factors which may include a genetic pre-disposition in combination with diabetic neuropathy. This leads to decreased neuropeptides (nitric oxide and calcitonin gene-related peptide), which may affect the normal coupling of bone formation and resorption, and increased levels of Receptor activator of nuclear factor kappa-B ligand, potentiating osteoclastogenesis.

Repetitive unrecognized trauma due to neuropathy increases levels of pro-inflammatory cytokines (interleukin-1β, interleukin-6, tumour necrosis factor α) which could also contribute to increased bone resorption, in combination with a pre-inflammatory state, with increased autoimmune reactivity and a profile of monocytes primed to transform into osteoclasts - cluster of differentiation 14 (CD14).

Increased blood glucose and loss of circulating Receptor for Advanced Glycation End-Products (AGLEPs), leading to increased non-enzymatic glycation of collagen and accumulation of AGLEPs in the tissues of the foot, may also contribute to the pathological process.

An understanding of the relative contributions of each of these mechanisms and a final common pathway for the development of Charcot neuroarthropathy are still lacking.

Cite this article: S. E. Johnson-Lynn, A. W. McCaskie, A. P. Coll, A. H. N. Robinson. Neuroarthropathy in diabetes: pathogenesis of Charcot arthropathy. Bone Joint Res 2018;7:373–378. DOI: 10.1302/2046-3758.75.BJR-2017-0334.R1.

Aims

The purpose of this study was to validate the diagnosis of periprosthetic joint infection (PJI) in the Danish Hip Arthroplasty Register (DHR).

Aims

The treatment of septic arthritis of the shoulder is challenging. The infection frequently recurs and the clinical outcome can be very poor. We aimed to review the outcomes following the use of continuous negative pressure after open debridement with a large diameter drain in patients with septic arthritis of the shoulder.

Aims

Periprosthetic joint infection (PJI) remains a challenging complication following total hip arthroplasty (THA). It is associated with high levels of morbidity, mortality and expense. Guidelines and protocols exist for the management of culture-positive patients. Managing culture-negative patients with a PJI poses a greater challenge to surgeons and the wider multidisciplinary team as clear guidance is lacking.

The purpose of this study was to evaluate whether the serum level of interleukin 6 (IL-6) could be used to identify the persistence of infection after the first stage of a two-stage revision for periprosthetic joint infection.

Between 2010 and 2011, we prospectively studied 55 patients (23 men, 32 women; mean age 69.5 years; 36 to 86) with a periprosthetic joint infection. Bacteria were identified in two intra-operative tissue samples during re-implantation in 16 patients. These cases were classified as representing persistent infection.

To calculate a precise cut-off value which could be used in everyday clinical practice, a 3 x 2 contingency table was constructed and manually defined.

We found that a serum IL-6 ≥ 13 pg/mL can be regarded as indicating infection: its positive-predictive value is 90.9%. A serum IL-6 ≤ 8 pg/mL can be regarded as indicating an absence of infection: its negative predictive value is 92.1%.

The serum IL-6 level seems to be a reasonable marker for identifying persistent infection after the first stage of a revision joint arthroplasty and before attempting re-implantation.

Cite this article: Bone Joint J 2015;97-B:71–5.

The aim of this study was to determine whether the high-sensitivity modified Glasgow prognostic score (Hs-mGPS) could predict the disease-specific survival and oncological outcome in adult patients with non-metastatic soft-tissue sarcoma before treatment. A total of 139 patients treated between 2001 and 2012 were retrospectively reviewed. The Hs-mGPS varied between 0 and 2. Patients with a score of 2 had a poorer disease-specific survival than patients with a score of 0 (p < 0.001). The estimated five-year rate of disease-specific survival for those with a score of 2 was 0%, compared with 85.4% (95% CI 77.3 to 93.5) for those with a score of 0. Those with a score of 2 also had a poorer disease-specific survival than those with a score of 1 (75.3%, 95% CI 55.8 to 94.8; p < 0.001). Patients with a score of 2 also had a poorer event-free rate than those with a score of 0 (p < 0.001). Those with a score of 2 also had a poorer event-free survival than did those with a score of 1 (p = 0.03). A multivariate analysis showed that the Hs-mGPS remained an independent predictor of survival and recurrence. The Hs-mGPS could be a useful prognostic marker in patients with a soft-tissue sarcoma.

Cite this article: Bone Joint J 2015; 97-B:847–52.

Periprosthetic joint infection (PJI) is a devastating complication for patients and results in greatly increased costs of care for both healthcare providers and patients. More than 15 500 revision hip and knee procedures were recorded in England, Wales and Northern Ireland in 2013, with infection accounting for 13% of revision hip and 23% of revision knee procedures.

We report our experience of using antibiotic eluting absorbable calcium sulphate beads in 15 patients (eight men and seven women with a mean age of 64.8 years; 41 to 83) as part of a treatment protocol for PJI in revision arthroplasty.

The mean follow-up was 16 months (12 to 22). We report the outcomes and complications, highlighting the risk of hypercalcaemia which occurred in three patients.

We recommend that serum levels of calcium be routinely sought following the implantation of absorbable calcium sulphate beads in orthopaedic surgery.

Cite this article: Bone Joint J 2015;97-B:1237–41.

In this retrospective observational cohort study, we describe 17 patients out of 1775 treated for various fractures who developed mycobacterium tuberculosis (MTB) infection after surgery. The cohort comprised 15 men and two women with a mean age of 40 years (24 to 70). A total of ten fractures were open and seven were closed. Of these, seven patients underwent intramedullary nailing of a fracture of the long bone, seven had fractures fixed with plates, two with Kirschner-wires and screws, and one had a hemiarthroplasty of the hip with an Austin Moore prosthesis. All patients were followed-up for two years. In all patients, the infection resolved, and in 14 the fractures united. Nonunion was seen in two patients one of whom underwent two-stage total hip arthroplasty (THA) and the other patient was treated using excision arthoplasty. Another patient was treated using two-stage THA. With only sporadic case reports in the literature, MTB infection is rarely clinically suspected, even in underdeveloped and developing countries, where pulmonary and other forms of TB are endemic. In developed countries there is also an increased incidence among immunocompromised patients. In this paper we discuss the pathogenesis and incidence of MTB infection after surgical management of fractures and suggest protocols for early diagnosis and management.

Cite this article: Bone Joint J 2015;97-B:1279–83.

Objectives

A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.

The December 2015 Research Roundup360 looks at: Biomarkers in periprosthetic joint infection; HbA1c and complications in arthroplasty; Getting to the bottom of biofilms; Effective antibiosis for biofilms; Stem cells and avascular necrosis; Predicting LOS in total joint arthroplasty; Long-term antibiotics reduce recurrence in periprosthetic infection

Aims

There are many guidelines that help direct the management of patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken a study to compare the management of patients with MOM hip arthroplasties in different countries.

Aims

Using a systematic review, we investigated whether there is an increased risk of post-operative infection in patients who have received an intra-articular corticosteroid injection to the hip for osteoarthritis prior to total hip arthroplasty (THA).

The common recommended treatment for infected total hip replacement is two-staged exchange including removal of all components. However, removal of well-fixed femoral stems can result in structural bone damage. We recently reported on an alternative treatment of partial two-stage exchange used in selected cases, in which a well-fixed femoral stem was left and only the acetabular component removed, the joint space was debrided thoroughly, an antibiotic-laden polymethylmethacrylate spacer was moulded using a bulb-type syringe and placed in the acetabulum, intravenous antibiotics were administered during the interval, and delayed re-implantation was performed. In 19 patients treated with this technique from January 2000 to January 2011, 89% were free of infection at a mean follow-up of four years (2 to 11). Since then, disposable silicone moulds have become available to fabricate spacers in separate femoral and head units. The head spacer mould, which incorporates various neck taper adapter options, greatly facilitates the technique of partial two-stage exchange. We report our early experience using disposable silicone head spacer moulds for partial two-stage exchange in seven patients with infected primary hip replacements.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):66–9

Objective

Mortality rates reported by the National Joint Registry for England and Wales (NJR) were higher following cemented total knee replacement (TKR) compared with uncemented procedures. The aim of this study is to examine and compare the effects of cemented and uncemented TKR on the activation of selected markers of inflammation, endothelium, and coagulation, and on the activation of selected cytokines involved in the various aspects of the systemic response following surgery.

To assess the sustainability of our institutional bone bank, we calculated the final product cost of fresh-frozen femoral head allografts and compared these costs with the use of commercial alternatives. Between 2007 and 2010 all quantifiable costs associated with allograft donor screening, harvesting, storage, and administration of femoral head allografts retrieved from patients undergoing elective hip replacement were analysed.

From 290 femoral head allografts harvested and stored as full (complete) head specimens or as two halves, 101 had to be withdrawn. In total, 104 full and 75 half heads were implanted in 152 recipients. The calculated final product costs were €1367 per full head. Compared with the use of commercially available processed allografts, a saving of at least €43 119 was realised over four-years (€10 780 per year) resulting in a cost-effective intervention at our institution. Assuming a price of between €1672 and €2149 per commercially purchased allograft, breakeven analysis revealed that implanting between 34 and 63 allografts per year equated to the total cost of bone banking.

Cite this article: Bone Joint J 2014;96-B:1307–11

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 Staphylococcus aureus and failed two-stage revision. In the pharmacokinetic study, the mean synovial vancomycin peak level was 9242 (3956 to 32 150; sd 7608 μg/mL) among the 11 patients studied. Serum trough level ranged from 4.2 to 25.2 μg/mL (mean, 12.3 μg/mL; average of 9.6% of the joint trough value), which exceeded minimal inhibitory concentration. The success rate exceeded 95% in the two clinical groups. IA delivery of antibiotics is shown to be safe and effective, and is now the first option for treatment of infected total joint arthroplasty in our institution.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):31–6.

Aims

We present a case series of ten metal-on-polyethylene total hip arthroplasties (MoP THAs) with delayed dislocation associated with unrecognised adverse local tissue reaction due to corrosion at the trunnion and pseudotumour formation.

We report the five year outcomes of a two-stage approach for infected total hip replacement. This is a single-surgeon experience at a tertiary centre where the more straightforward cases are treated using single-stage exchange. This study highlights the vital role of the multidisciplinary team in managing these cases.

A total of 125 patients (51 male, 74 female) with a mean age of 68 years (42 to 78) were reviewed prospectively. Functional status was assessed using the Harris hip score (HHS). The mean HHS improved from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively. Staphylococcus species were isolated in 85 patients (68%).

The rate of control of infection was 96% at five years. In all, 19 patients died during the period of the study. This represented a one year mortality of 0.8% and an overall mortality of 15.2% at five years. No patients were lost to follow-up.

We report excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach. The reason for the high rate of mortality in these patients is not known.

Cite this article: Bone Joint J 2014;96-B:1312–18

The August 2015 Oncology Roundup³⁶⁰ looks at: Glasgow prognostic score in soft-tissue sarcoma; Denosumab in giant cell tumour; Timing, complications and radiotherapy; Pigmented villonodular synovitis and arthroscopy; PATHFx: estimating survival in pathological cancer; Prosthetic lengthening of short stumps; Chondrosarcoma and pathological fracture