There have been only a few small studies of patients with an infected shoulder replacement treated with a single-stage exchange procedure. We retrospectively reviewed 35 patients (19 men and 16 women) with a peri-prosthetic infection of the shoulder who were treated in this way. A total of 26 were available for clinical examination; three had died, two were lost to follow-up and four patients had undergone revision surgery. The mean follow-up time was 4.7 years (1.1 to 13.25), with an infection-free survival of 94%.

The organisms most commonly isolated intra-operatively were Staphylococcus epidermidis and Propionibacterium acnes; two patients developed a recurrent infection. Three different types of prosthesis were used: a hemiarthroplasty, a hemiarthroplasty with a bipolar head and reverse prosthesis. The mean Constant-Murley score at final follow-up was 43.3 (14 to 90) for patients with a hemiarthroplasty, 56 (40 to 88) for those with a hemiarthroplasty with a bipolar head and 61 (7 to 90) for those with a reverse prosthesis. The mean hospital stay was 10.6 days (5 to 29).

Single-stage exchange is a successful and practical treatment for patients with peri-prosthetic infection of the shoulder.

Cite this article: Bone Joint J 2013;95-B:391–5.

It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery.

Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb.

Cite this article: Bone Joint J 2013;95-B:558–62.

Loss of proprioception following an anterior cruciate ligament (ACL) injury has been well documented. We evaluated proprioception in both the injured and the uninjured limb in 25 patients with ACL injury and in 25 healthy controls, as assessed by joint position sense (JPS), the threshold for the detection of passive movement (TDPM) and postural sway during single-limb stance on a force plate. There were significant proprioceptive deficits in both ACL-deficient and uninjured knees compared with control knees, as assessed by the angle reproduction test (on JPS) and postural sway on single limb stance. The degree of loss of proprioception in the ACL-deficient knee and the unaffected contralateral knee joint in the same patient was similar. The TDPM in the injured knee was significantly higher than that of controls at 30° and 70° of flexion. The TDPM of the contralateral knee joint was not significantly different from that in controls.

Based on these findings, the effect of proprioceptive training of the contralateral uninjured knee should be explored.

Cite this article: Bone Joint J 2013;95-B:188–91.

More than a million hip replacements are carried out each year worldwide, and the number of other artificial joints inserted is also rising, so that infections associated with arthroplasties have become more common. However, there is a paucity of literature on infections due to haematogenous seeding following dental procedures. We reviewed the published literature to establish the current knowledge on this problem and to determine the evidence for routine antibiotic prophylaxis prior to a dental procedure.

We found that antimicrobial prophylaxis before dental interventions in patients with artificial joints lacks evidence-based information and thus cannot be universally recommended.

Objectives

To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care.

The February 2013 Spine Roundup³⁶⁰ looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses.

The February 2013 Trauma Roundup³⁶⁰ looks at: the risk of ankle fractures; absorbable implants; minimally invasive heel fracture fixation; pertrochanteric fractures; arthroplasty and intracapsular hip fractures; and extensor mechanism disruption.

We describe a retrospective review of the clinical and radiological parameters of 32 feet in 30 patients (10 men and 20 women) who underwent correction for malalignment of the hindfoot with a modified double arthrodesis through a medial approach. The mean follow-up was 21 months (13 to 37). Fusion was achieved in all feet at a mean of 13 weeks (6 to 30). Apart from the calcaneal pitch angle, all angular measurements improved significantly after surgery. Primary wound healing occurred without complications.

The isolated medial approach to the subtalar and talonavicular joints allows good visualisation which facilitated the reduction and positioning of the joints. It was also associated with fewer problems with wound healing than the standard lateral approach.

The December 2012 Knee Roundup³⁶⁰ looks at: the demand for knee replacement; a Japanese knee outcome score; smoking and TKR; coronal alignment as a determinant of outcome in TKR; fixed flexion; MRI detected knee lesions; and lateral domed Oxford unicompartmental knee replacements.

Most problems encountered in complex revision total knee arthroplasty can be managed with the wide range of implant systems currently available. Modular metaphyseal sleeves, metallic augments and cones provide stability even with significant bone loss. Hinged designs substitute for significant ligamentous deficiencies. Catastrophic failure that precludes successful reconstruction can be encountered. The alternatives to arthroplasty in such drastic situations include knee arthrodesis, resection arthroplasty and amputation. The relative indications for the selection of these alternatives are recurrent deep infection, immunocompromised host, and extensive non-reconstructible bone or soft-tissue defects.

We carried out a retrospective cohort study of 3309 patients undergoing primary total hip replacement to examine the impact of tobacco use and body mass index on the length of stay in hospital and the risk of short term post-operative complications.

Heavy tobacco use was associated with an increased risk of systemic post-operative complications (p = 0.004). Previous and current smokers had a 43% and 56% increased risk of systemic complications, respectively, when compared with non-smokers. In heavy smokers, the risk increased by 121%. A high body mass index was significantly associated with an increased mean length of stay in hospital of between 4.7% and 7%. The risk of systemic complications was increased by 58% in the obese. Smoking and body mass index were not significantly related to the development of local complications.

Greater efforts should be taken to reduce the impact of preventable life style factors, such as smoking and high body mass index, on the post-operative course of total hip replacement.

We have conducted a case-control study over a period of ten years comparing both deep infection with methicillin-resistant staphylococcus aureus (MRSA) and colonised cases with a control group.

Risk factors associated with deep infection were vascular diseases, chronic obstructive pulmonary disease, admission to a high-dependency or an intensive-care unit and open wounds. Those for colonisation were institutional care, vascular diseases and dementia. Older age was a risk factor for any MRSA infection. The length of hospital stay was dramatically increased by deep infection.

These risk factors are useful in identifying higher-risk patients who may be more susceptible to MRSA infection. A strategy of early identification and isolation may help to control its spread in trauma units.

Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis.

Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10).

Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism.

The December 2012 Hip & Pelvis Roundup³⁶⁰ looks at: swimming against the tide with resurfacing; hip impingement surgery; the relationship between obesity and co-morbidities and joint replacement infection; cemented hips; cross-linked polyethylene notching; whether cement is necessary in oncological arthroplasty; and how total hip replacement may result in weight gain.

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion.

This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures.

We retrospectively reviewed 279 patients (99 obese (BMI ≥ 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function.

These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed.

The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal.

We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head.

Necrotising fasciitis is a rare but severe infection of soft-tissue associated with rapid progression, systemic toxicity and high mortality. Monomicrobial necrotising fasciitis caused by Pseudomonas aeruginosa is exceptionally uncommon with only 12 cases reported in the literature. We describe a fatal case with an atypical presentation in a patient following spinal decompression for a metastasis from prostate cancer.

The October 2012 Wrist & Hand Roundup³⁶⁰ looks at: osteoarticular flaps to the PIPJ; prognosis after wrist arthroscopy; adipofascial flaps and post-traumatic adhesions; the torn TFCC alone; ulna-shortening osteotomy for ulnar impaction syndrome; Dupuytren’s disease; when a wrist sprain is not a sprain; and shrinking the torn intercarpal ligament.

The October 2012 Trauma Roundup³⁶⁰ looks at: which patients die from pelvic ring fractures; monolateral distraction osteogenesis; surgical management of pelvic and peroneal blast injuries; weekend warriors at risk of going AWOL; early experience with the locking attachment plate; and fibula nailing - an alternate, and viable technique.

Periprosthetic joint infection (PJI) is a devastating complication which can follow a total joint arthroplasty (TJA). Although rare, this ongoing threat undermines the success of TJA, a historically reputable procedure. It has haunted the orthopedic community for decades and several ongoing studies have provided insights and new approaches to effectively battle this multilayered problem.