Girdlestone resection arthroplasty following failed surgical procedures

Hip-resection arthroplasty: A valuable treatment for complex hip prosthetic joint infection?

INTRODUCTION

Management of recurrent hip prosthetic joint infection (PJI) is challenging. Hip-resection arthroplasty is a last-choice rescue strategy for complex PJI. The main objective was to assess prospectively the mid-term infectious and functional PJI outcomes of patients managed with hip-resection arthroplasty.

HYPOTHESIS

In complex multi-operated PJI, hip-resection arthroplasty may cure the infection without any major impact on hip function, which is often already very limited.

MATERIAL AND METHODS

This prospective cohort study conducted in a French Referral Center for bone-and-joint infections included all hip PJIs treated with hip-resection arthroplasty from 2004 to 2019. Patients were followed for at least 2 years, with recording of the following events: reinfection, including relapse or new infection, and PJI-related death. Hip functional status was assessed with the modified Merle d'Aubigné-Postel (mMAP) score. The primary outcome was 2-year event-free survival (EFS). The secondary outcomes were the 4- and 6-year EFS rates and hip functional status at 2 years.

RESULTS

We included 30 patients: median age, 65 years; 39% women. Median [IQR] PJI duration was 15 [4-39] months and patients underwent a median of 5 surgical procedures before resection arthroplasty. The 2-year reinfection free-survival was 89.2% (95% CI: 70.2-96.4). After a median follow-up of 70 [32-103] months, we observed: 1 relapse, 4 new infections, 7 revisions for mechanical reasons and 1 PJI-related death. Median mMAP score 2 years postsurgery was 12, versus 7 before; pain reduction was the main benefit of resection arthroplasty.

DISCUSSION

Hip-resection arthroplasty achieves sepsis and pain control, and can be a valuable last-line rescue strategy for patients with complex or recurrent hip PJIs.

LEVEL OF EVIDENCE

II; monocentric prospective cohort.

Retrograde Nailing for a Rare Post-Girdlestone Femur Fracture: A Case Report

Femur shaft fractures are common in orthopedic practice, but their occurrence following Girdlestone resection arthroplasty (GRA) is extremely rare. We report the case of an unusual ipsilateral femoral shaft fracture after a ground-level fall in a patient who underwent hip resection arthroplasty nine years earlier due to prosthetic joint infection. The fracture was treated successfully with closed reduction and retrograde intramedullary nailing, enabling the patient to resume ambulation with pre-injury assistance levels. This case highlights the importance of understanding biomechanical implications in patients with GRA and demonstrates the efficacy of retrograde nailing in managing such rare fractures.

Femoral nerve palsy following Girdlestone resection arthroplasty: An observational cadaveric study

BACKGROUND

When patients with a failed hip arthroplasty are unsuitable for reimplantation, Girdlestone resection arthroplasty (GRA) is a viable treatment option. We report on a patient who was treated with a GRA due to a periprosthetic infection. We discovered partial paralysis of the quadriceps muscle in this patient. We investigated the femoral nerve anatomy, particularly the nerve entry points, to better understand this phenomenon.

AIM

To reveal the femoral nerve anatomy with respect to severe proximal migration after GRA.

METHODS

Eight cadaveric hemipelves were investigated. The branches of the femoral nerve were dissected and traced distally. The GRA was performed by the direct anterior approach. Axial stress to the lower extremity was applied, and the relative movement of the femur was recorded. The femoral nerve and its entry points were assessed.

RESULTS

GRA led to a 3.8 cm shift of the femur in vertical direction, a 1.8 cm shift in the dorsal direction, and a 2.3 cm shift in the lateral direction. A 36.5° external shift was observed. This caused stress to the lateral division of the femoral nerve. We observed migration of the femoral nerve entry point at the following locations: (1) Vastus medialis (5.3 mm); (2) The medial part of the vastus intermedius (5.4 mm); (3) The lateral part of the vastus intermedius (16.3 mm); (4) Rectus femoris (23.1 mm); (5) Tensor vastus intermedius (30.8 mm); and (6) Vastus lateralis (28.8 mm).

CONCLUSION

Migration of the femur after GRA altered the anatomy of the femoral nerve. Stress occurred at the lateral nerve division leading to poor functional results.

Hip Resection Arthroplasty as Definitive Treatment: Indications, Outcomes, and Complications in Paraplegic and Non-Paraplegic Patients

BACKGROUND

Hip resection arthroplasty (HRA) serves as a salvage treatment option for various conditions affecting paraplegic patients. In nonparaplegic individuals, it is often utilized to manage complex infections. There exists a paucity of studies comparing outcomes between paraplegic and nonparaplegic patients undergoing HRA as definitive treatment. This study aimed to analyze the demographics, indications, outcomes, and complications in these two patient groups.

METHODS

A retrospective analysis was conducted on 65 patients who underwent HRA, divided into paraplegic (n = 25) and nonparaplegic (n = 40) groups. Data encompassed demographics, preoperative indications, postoperative complications, and outcomes.

RESULTS

Paraplegic patients exhibited distinct characteristics compared to nonparaplegic counterparts, including younger age (P < 0.001), lower comorbidity scores (P = 0.013), fewer prior hip operations (P = 0.002), and a higher proportion of men (P < 0.001). Septic arthritis emerged as the primary indication for definitive HRA in both groups, constituting 64% of paraplegic and 42.5% of nonparaplegic cases. Nonparaplegic patients experienced a significant reduction in pain scores postoperatively (P < 0.001), with a notable improvement in mobility. Infection eradication rates were comparable between the two groups, with 82 and 92% success rates in paraplegic and nonparaplegic cases, respectively. However, paraplegic patients exhibited a higher reoperation rate (P = 0.041), while nonparaplegic individuals encountered increased major systemic complications (P = 0.052). Although the total complication rate was slightly higher in the nonparaplegic group (75 versus 56%), the difference was not statistically significant (P = 0.211).

CONCLUSIONS

An HRA was the definitive treatment that successfully treated infection in both groups. In the nonparaplegic group, it led to enhanced ambulatory capacity and decreased pain. Paraplegic patients experienced higher rates of reoperation, whereas nonparaplegic patients suffered from greater rates of major systemic complications. These findings provide valuable insights for clinicians considering HRA as a definitive treatment.

Poor Outcomes of Girdlestone Resection Arthroplasty in Injection Drug Users: A Retrospective Study

This retrospective cohort study aims to investigate the clinical outcomes of Girdlestone resection arthroplasty (GRA) in injection drug users with septic hip arthritis. Patients who underwent primary GRA for septic hip arthritis secondary to injection drug use at two academic trauma centers from 2015 to 2023 were retrospectively reviewed. Patient demographics, surgical details, and follow-up outcomes, including patient-reported outcome measures, were collected and analyzed. The cohort included 15 patients, with a mean age of 44 ± 11 years and a mean follow-up period of 25 ± 20 months. Among the 15 patients, overall mortality was 27%, and only 4 patients underwent total hip arthroplasty (THA) following GRA. Infection resolution rates were significantly higher in patients who received an antibiotic spacer (75% vs. 0%, p = 0.048). GRA in injection drug users is associated with high mortality and low conversion rates to THA. The use of an antibiotic spacer during GRA significantly improves infection resolution rates. Larger studies are required to determine the optimal management strategies for this patient population.

Girdlestone resection arthroplasty of the hip (GRA): a case series-outdated procedure or acceptable outcome?

Despite considerable legacy issues, Girdlestone's resection arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical co-morbidities which preclude staged or significant surgical interventions, and/or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

Girdlestone resection arthroplasty for femoral neck fractures has poorer outcomes than hemiarthroplasty in frail patients with increased risk for arthroplasty-related complications: a retrospective case study of 21 patients

BACKGROUND AND PURPOSE

Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes.

PATIENTS AND METHODS

21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015-2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan-Meier analysis. The mean follow-up (FU) was 1.5 (0-4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score.

RESULTS

The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0-50] vs. 46 [11-80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group.

CONCLUSION

Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.

What is the outcome after a Girdlestone resection arthroplasty following a hip fracture?

BACKGROUND

Joint infections or the complications of hip surgery may necessitate a Girdlestone resection arthroplasty. This is often kept as a last resort for patients with significant co-morbidities or when other treatments have been ineffective. The aim of this study was to define the outcome after Girdlestone excision arthroplasty when undertaken as a primary or secondary procedure for a hip fracture.

PATIENTS AND METHODS

This is a retrospective review of a prospectively collected database involving 36 patients who underwent a Girdlestone procedure over a 30-year period. It compares the outcome for the 19 patients who survived to 1 year with those of 38 matched hip fracture patients.

RESULTS

Pain persisted in most patients after the procedure and was universal in those patients who could walk. Most patients experienced a significant loss of independence and a reduction in mobility status: 12/19 (63.1%) of those who survived to 1 year were immobile and of the remainder, all needed a Zimmer frame to walk. Overall, 41.7% of patients had died within 1 year of undergoing the procedure.

CONCLUSIONS

This study concludes that Girdlestone resection arthroplasty after a hip fracture is associated with a high degree of morbidity and mortality and therefore, should only be used as a salvage procedure after all other surgical measures have been exhausted.

Cure rate of infections is not an argument for spacer in two-stage revision arthroplasty of the hip

INTRODUCTION

 A devastating complication after total hip arthroplasty (THA) is chronic periprosthetic joint infection (PJI). Most frequently spacers (Sp) with or without antibiotics are implanted in a two-stage procedure even though not always indicated due to unknown pathogen, femoral and acetabular defects or muscular insufficiency.

MATERIALS AND METHODS

 A retrospective analysis of a prospectively collected database was conducted, analyzing the treatment of 44 consecutive cases with chronic PJI undergoing two-stage revision using a Girdlestone situation (GS) in the interim period between 01/2015 and 12/2018. Diagnostics included intraoperative microbiological cultures, histological analysis, sonication of the initial implant, analysis of hip aspiration, as well as laboratory diagnostics and blood cultures. We analyzed the general and age-group-specific success rate of treatment using GS. Furthermore, we compared our data with the current literature on spacer implantation regarding common complications.

RESULTS

In total, 21 female and 23 male patients at a mean age of 59.3 ± 9.6 years were included. Age groups were divided into young, mid-age, and elderly. In most patients, microbiology revealed Staphylococcus epidermidis in 39.1% of cases, following Staphylococcus lugdunensis and Staphylococcus aureus in 10.9% after THA explantation. For histology, Krenn and Morawietz type 2 (infectious type) was diagnosed in 40.9%, type 3 (infectious and abrade-induced type) in 25.0%. With GS, the total cure rate was 84.1% compared to 90.1% (range 61-100%) using Sp as described in the literature. Among age-groups, cure rate varied between 77.8 and 100%. Other complications, which only occurred in the mid-age and elderly group, included the necessity of transfusion in 31.1%, and in total, one periprosthetic fracture was identified (2.3%).

CONCLUSION

GS shows an acceptable cure rate at a minimum of 2 years when compared to the cure rate reported in the literature for Sp without major complications. For patients with increased risks for treatment failure using spacer, GS seems to be an alternative for chronic PJI when looking at the success rate of treatment.

LEVEL OF EVIDENCE

III, Retrospective trial.

Treating Hepatitis C Prior to Total Hip Arthroplasty is Cost Effective: A Markov Analysis

INTRODUCTION

Patients infected with the hepatitis C virus (HCV) have high complication rates following total hip arthroplasty (THA). Advances in HCV therapy now enable clinicians to eradicate the disease, however, its cost effectiveness from an orthopaedic perspective remains to be demonstrated. We sought to conduct a cost effectiveness analysis comparing no therapy to direct acting antiviral therapy (DAA) prior to THA among HCV positive patients.

METHODS

A Markov model was utilized to evaluate the cost-effectiveness of treating HCV with DAA prior to THA. The model was powered with event probabilities, mortality, cost and quality adjusted life-year values for patients with and without HCV that were obtained from the published literature. This included treatment costs, successes of HCV eradication, incidences of superficial or periprosthetic joint infection (PJI), probabilities of utilizing various PJI treatment modalities, PJI treatment success/failures, and mortality rates. The incremental cost-effectiveness ratio (ICER) was compared to a willingness-to-pay threshold of $50,000/QALY.

RESULTS

Our Markov model indicates that in comparison to no therapy, DAA prior to THA is cost-effective for HCV positive patients. THA in the setting of no therapy and DAA added 8.06 and 14.39 QALYs at a mean cost of $28,800 and $115,800. The ICER associated with HCV DAA in comparison to no therapy was $13,800/QALY, below the willingness-to-pay threshold of $50,000/QALY.

CONCLUSION

Hepatitis-C treatment with DAA prior to THA is cost-effective at all current drug list prices. Given these findings, strong consideration should be given to treating patients for HCV prior to elective THA.

Is hip resection arthroplasty a successful definitive treatment?

Purpose

Hip resection arthroplasty as a definitive treatment is an uncommon indication, although still in use selectively. This study evaluates a cohort of patients who have undergone hip resection arthroplasty surgery indicated as a definitive treatment, in order to assess the rate of re-operation, the rate of infection, and the mortality rates.

Methods

We conducted a retrospective, observational, descriptive analysis of a cohort of patients who had undergone a hip resection arthroplasty intended as a definitive treatment, in two University Hospitals from 1994 to 2020. The exclusion criteria were the implantation of a hip cement spacer, or a temporary hip resection arthroplasty in patients undergoing a two-staged surgical approach. We found 26 cases of hip resection arthroplasty. We recorded the indications for a definitive hip resection arthroplasty, the outcomes and complications, and analyzed the success of the hip resection arthroplasty as a definitive surgery using a Kaplan-Meier curve.

Results

Seven cases (26.9%) required a re-operation after the hip resection arthroplasty, four cases for persistent hip infection, and in the three remaining a conversion to a total hip arthroplasty was re-considered due to a good medical evolution and non-tolerance to the low functional outcome. The mortality rate was 61.5% (27 days-20 years), with a 19.2% mortality rate in the first 5 years. All the cases that required another surgery after the hip resection arthroplasty were re-operated within the first 18 months.

Conclusion

Unfortunately, hip resection arthroplasty continues to show elevated re-operation rate and early mortality rate, as well as low functional outcomes. Two-staged hip revision arthroplasty is the surgical treatment of choice in patients suffering from a periprosthetic joint infection, however we believe that hip resection arthroplasty should be considered in fragile patients, who have endured multiple revision surgeries, or their comorbidities make them unfit from further surgeries.

A Multicenter Prospective Investigation on Patient Physical and Mental Health After Girdlestone Resection Arthroplasty

BACKGROUND

Girdlestone resection arthroplasty is a salvage procedure for hip periprosthetic joint infection (PJI) that controls infection and reduces chronic pain, but may result in limited postoperative joint function. The aim of this study was to assess physical function and mental health after Girdlestone.

METHODS

This was a multicenter, prospective study evaluating patients with Girdlestone. The Prosthesis Evaluation Questionnaire (PEQ) and patient-reported outcomes measurement information system (PROMIS) global physical health and mental health surveys were administered postoperatively via telephone. The PEQ consists of four scales (ie, ambulation, frustration, perceived response, and social burden) with scores ranging from 0 to 10. The PROMIS measures generated T-scores (mean: 50, standard deviation: 10) that enable comparison to the general population.

RESULTS

Thirty-five patients completed all surveys. The average time from procedure to survey completion was 6 years (range, 1 to 20). The median scores for the ambulation, frustration, perceived response, and social burden scales of the PEQ were 0.0 [interquartile range: 0-4.1], 6.0 [3.0-9.3], 9.0 [7.2-10.0], and 7.5 [4.3-9.5]. The median raw scores of the PROMIS global physical health and mental health were 11.91 [interquartile range: 9-14] and 14.0 [10.0-16.0]. These corresponded to average T scores of 39.7 (standard error : 4.3) for physical health and 46.1 (standard error: 3.8) for mental health, which were 10.3 points and 3.9 points below the average score in the United States general population, respectively.

CONCLUSION

Girdlestone can have a substantial negative impact on physical functions; however, mental health and social interaction may be only moderately affected. These outcomes can be used to guide patient expectations, as this procedure may be necessary in certain salvage scenarios.

Analysis of perioperative outcomes in hip resection arthroplasty

BACKGROUND

Hip resection arthroplasty (HRA) is a salvage surgical technique for the management of complex hip conditions wherein arthroplasty may be contraindicated. The purpose of this study was to review modern-day indications for HRA and compare outcomes between patients undergoing HRA and revision total hip arthroplasty (RTHA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients undergoing HRA or RTHA between 2012 and 2017. Patient demographics, risk factors, and perioperative complications were analyzed. Multivariate regression was used to determine predictors of early postoperative complications. Propensity score matching (PSM) was performed to compare relative risks (RR) of complications in HRA compared to RTHA.

RESULTS

290 patients underwent HRA between 2012 and 2017. Infection was the most common indication for HRA (39.8%), followed by femoral neck fracture or malunion/nonunion (26%) and prosthetic instability (12.2%). Increased body mass index (BMI) (p = 0.012) and chronic obstructive pulmonary disease (COPD) (p = 0.007) were associated with increased risk of complication in HRA. There were no significant differences in short-term complication risks between RTHA and HRA.

CONCLUSIONS

HRA was associated with short-term complication rates comparable to RTHA. These findings may help in surgical decision-making and appropriate indications in the present day.

LEVEL OF EVIDENCE

III.

Osteoradionecrosis of the Hip, a Troublesome Complication of Radiation Therapy: Case Series and Systematic Review

Background

Osteoradionecrosis of the hip is a serious complication of radiotherapy that is easily overlooked by physicians and patients in the early stages. There are relatively few reports on this subject, so there is no clear scientific consensus for the pathogenesis, early diagnosis, and clinical treatment of hip osteoradionecrosis. In this paper, we report two cases of hip osteoradionecrosis and systematically review the related literature.

Case Presentation

We report two cases of hip osteoradionecrosis. One patient successfully underwent total hip arthroplasty in our hospital and recovered well postoperatively. Another patient although we offered a variety of surgical options for this patient, the patient was worried that the bone loss would lead to poor prosthesis fixation, resulting in prosthesis loosening and infection, and therefore ultimately refused surgical treatment.

Conclusion

With the development of radiological techniques, the incidence of hip osteoradionecrosis is decreasing year by year, but early diagnosis and rational treatment remain challenging. The effects of non-surgical treatment are limited. Early prevention, early detection, and early intervention are crucial to delay or prevent the emergence of more serious complications.

Revision arthroplasty with megaprosthesis after Girdlestone procedure for periprosthetic joint infection as an option in massive acetabular and femoral bone defects

BACKGROUND AND AIM

To evaluate the clinical outcomes of patients treated with Girdlestone procedure (GP) or excision arthroplasty (EA) for periprosthetic infection with massive bone defects and undergoing revision arthroplasty.

METHODS

All patients treated with EA or GP for hip periprosthetic infection between 2014 and 2017 and sustaining revision arthroplasty (RA) were included in the study. Patients with less than 24 months of follow-up or less than 12 months between GP or EA and RA were excluded. Any sign of implant mobilization or periprosthetic fracture was assessed through X-ray. Patients were evaluated with D'aubignè-Postel hip score before RA and at the last follow-up. Mann-Whitney U test was used to assess differences between pre-RA surgery and last follow-up. P value was set as <0.05.

RESULTS

Twelve patients meet the inclusion criteria (mean follow-up 58+/-9.72 months). No radiographic sign of implant mobilization or periprosthetic fracture was reported. A significant difference was found for each parameter of the D'Aubigne-Postel score (p < 0.0001); none of the patients reached more than fair results in the absolute hip score. The difference between pre and post-operative global status showed a fair improvement. A significant difference was found for leg length discrepancy between pre and post RA (p<0.0001).

CONCLUSIONS

Conversion from EA or GP to RA in patients suffering from massive acetabular and femur defects is challenging; conversion procedure is able to reduce patients' disability and to improve walking ability. (www.actabiomedica.it).

Factors associated with infection recurrence after two-stage exchange for periprosthetic hip infection

PURPOSE

Two-stage exchange is the treatment of choice for periprosthetic joint infection (PJI). Factors and outcomes associated with infection recurrence for hip PJI are limited. The primary aim of this study was to determine factors associated with infection recurrence after two-stage exchange. Secondary aims were survival, mobility, and the EuroQol five-dimension scale (EQ-5D-5L) health state.

METHODS

We retrospectively investigated patients with two-stage exchange for hip PJI at our institution from 2006 to 2017. Follow-up was conducted for a minimum of four years after the reimplantation.

RESULTS

We included 135 patients with 139 hip PJIs. The mean age of the patients was 69.6 years (range 32-88). The infection recurrence rate was 14.4% (n = 20) after a mean follow-up of 8.0 years (range 4.0-13.1). Four factors for recurrence were identified at the time of the first stage: previous orthopaedic diagnoses (p < 0.001), type of explanted prosthesis (p = 0.004), cultured microorganisms (p = 0.033), and sinus tract (p = 0.035). A longer surgical reimplantation time (p = 0.015) was the only one factor found at the second stage. The estimated Kaplan-Meier survival for the total sample was 9.0 years (95% confidence interval 8.3-9.8), without significant difference for those with infection recurrence compared to recurrence-free patients (log-rank 0.931). At the time of follow-up, 89 patients were alive. For these patients, Parker mobility score (p = 0.102), EuroQol five-dimensional scale (p = 0.099), and EQ Visual Analogue Scale (EQ-VAS) (p = 0.027) were inferior in those with infection recurrence, but significance was found only for VAS.

CONCLUSION

In this study with mid- to long-term follow-up, five factors for infection recurrence were identified. Recurrence did not affect survival, but health-related quality of life was inferior compared to recurrence-free patients. The results suggest that the period of the first stage including previous orthopaedic diagnoses requires more consideration in the future.

Hip resection arthroplasty for acute femoral neck fractures in the non-ambulator

Objectives:

Hemiarthroplasty (HA) is the current standard of care for displaced femoral neck fractures (FNFs) in non-ambulators. Despite excellent outcomes, arthroplasty-specific risks remain, including dislocation, implant failure, periprosthetic fracture and infection, and fat embolization syndrome. To eliminate the possibility of these complications, should non-ambulatory patients with acute, native hip FNFs be treated with simple hip resection arthroplasty (HRA) instead of HA?

Design:

Retrospective case series.

Setting:

Large, urban level-1 trauma center.

Patients/Participants:

Five non-ambulatory patients (6 hips) with acute, native hip FNF underwent femoral head and neck resection. Also, the most recent 10 FNFs treated with HA were also identified for comparison purposes.

Intervention:

HRA was performed via a Smith-Peterson approach with an oscillating saw or osteotome to complete the fracture or perform a fresh neck cut.

Main Outcome Measurements:

Outcomes included postoperative vs preoperative VAS pain scores and narcotics usage, and return to baseline functional status (sit up in bed or a chair postoperatively). Procedure time for HRA was compared with the 10 most recent patients with FNF treated with HA.

Results:

HRA resulted in decreased postoperative vs preoperative VAS pain scores (7.7 vs 3.3, P = .002), and decreased operative times (59.2 minutes for HRA, 111.8 minutes for HA, P < .001). All HRA patients had immediate return of baseline function.

Conclusion:

HRA offers shorter operative times when compared with HA, decreased postoperative VAS pain scores, and immediate return to functional baseline status without possibility of arthroplasty-specific complications. HRA may be an acceptable treatment option for FNFs in the non-ambulator.

Level of evidence: IV

Use of muscular flaps for the treatment of hip prosthetic joint infection: a systematic review

BACKGROUND

Deep periprosthetic infection after total hip arthroplasty (THA) is a serious and challenging complication for the orthopedic surgeon. Muscular flaps may represent a valid management option for the treatment of this condition. We present a systematic literature review about the use of muscular flaps for the treatment of hip prosthetic joint infection.

METHODS

The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventy-seven articles, out of 279 titles, were considered eligible for the full-text analysis. Finally 15 studies that met inclusion criteria were included in this review.

RESULTS

Overall, 210 patients (49% males, 48.6% females and 2.4% not reported) suffering from THA infection treated with muscular flaps were collected. The mean age was 69.6 years. Mean follow-up, reported in all studies, was 3.3 years. The results presented by the different authors, highlight the effectiveness of muscular flaps for the treatment of periprosthetic infection, in terms of function, limb salvage, prevention of the recurrences, cost-effectiveness, and quality of life postoperatively.

CONCLUSIONS

Muscle flaps provide an excellent management option for patients with persistent infection after total hip arthroplasty.

Femoral Neck Osteotomy: A Salvage Procedure for Unstable and Locked Acetabulum Fractures in Selected Frail Patients

INTRODUCTION

Purpose of the study is to present and discuss the femoral neck osteotomy as a salvage procedure for unstable, locked geriatric acetabular fractures in selected frail patients. When disadvantages and possible risks of other treatments exceed the benefits, this method may relieve pain and allow for early wheelchair mobilization in frail patients with limited mobility.

MATERIALS AND METHODS

We report nine patients from 2008 to 2020, which were treated with an osteotomy of the femoral neck for an unstable acetabular fracture. Indications, ASA-Score, Frailty Index, operative procedure, length of hospital stay, complications and outcomes will be discussed.

RESULTS

Patient's age averaged 86 years (range 81-92). Acetabular fractures were classified as six both column fractures, two anterior column posterior hemitransversal fractures and one destruction of the acetabulum by multiple metastases. Fracture dislocation with medialization plus locking of the femoral head and a superomedial dome impaction were present in all patients. All patients were classified as ASA III/ IV and the average value on the CSHA Frailty index was 7 (range 6-7). The operation time averaged 52 min (range 34-62). Immediate wheelchair mobilization in seven out of nine patients was started postoperatively.

CONCLUSION

The osteotomy of the femoral neck may be discussed as a salvage procedure in low functional demanding, multimorbid, frail geriatric patients with unstable acetabular fractures and impairment of mobilisation due to a locked femoral head. The procedure has the advantages of a short operation time and immediate mobilization of the patients. However, this procedure only applies as a salvage solution in selected individual cases.

Simultaneous primary bilateral hip resection arthroplasty

Hip resection arthroplasty is a useful procedure for the management of complex hip problems and in patients with high surgical and anesthetic risk factors. Unilateral procedures performed for failed total hip arthroplasty have been shown to be successful for pain relief with acceptable functional outcomes; however, to our knowledge, no research exists on simultaneous bilateral hip resection arthroplasty for femoral head osteonecrosis. We present two cases of single-stage bilateral hip resection arthroplasty performed under singular anesthetic procedures for femoral head osteonecrosis. The patients were each able to stand for transfers postoperatively and had no deterioration in pain or function. These two cases demonstrate that satisfactory pain control with preservation of function may be achievable with bilateral hip resection arthroplasty procedures in patients who are not a candidate for more advanced reconstructive procedures.

Functional outcomes of an adult with osteogenesis imperfecta after rehabilitation post bilateral Girdlestone procedure

This is a case of a 54-year-old woman managed as a case of osteogenesis imperfecta type 1 who sustained a left subtrochanteric fracture and eventual ankylosis of both hips after surgery and immobilisation. These injuries rendered her bedridden, maximally assisted in transitions and transfers, and unable to be positioned past 30° of backrest elevation. The patient underwent a bilateral Girdlestone procedure and had tailored progressive postoperative rehabilitation in both the inpatient and outpatient settings. The patient also continued to receive bisphosphonates during her preoperative and postoperative period, to improve bone stock and aid in relieving pain. Through the efforts of a team of physiatrists, geneticists and orthopaedic surgeons, the patient was able to achieve pain-free sitting, independent transitions and short-distance ambulation, which have allowed her to care for herself more effectively and return to her work and activities of daily living.

Outcome of proximal femur replacement in failed internal fixation of hip fractures, a case series

Introduction

Failure of hip implant surgeries can be caused by various factors. Failure of internal fixation results in pain and restricted ambulation. In management of an elderly patient with hip fractures, the aim is to ambulate patient. The purpose of our study is to assess the outcomes of proximal femur replacement in the management of failed hip surgeries for fractures of the proximal femur.

Materials and methods

A retrospective analysis of 26 patients, who underwent proximal femur replacement for failed surgeries of hip fracture during the period from April 2011 to March 2018, was conducted. All patients who underwent proximal femur replacement for failed hip implants were enrolled into the study.

Results

Total patients were 26. The mean follow was (12–91 months). The mean Harris Hip score improved from 26 preoperative to 66.7(45–91). Three patients developed dislocations which were managed with closed reduction. Three patients died within one year of surgery, one patent died of sepsis from implant infection at four months after surgery, one patient died of Myocardial infarction. Three patients developed surgical site infection of which one has superficial surgical site infection which was managed with oral antibiotics, in other case developed deep surgical site infection and was managed with wound debridement and IV antibiotics for 6 weeks, in third wound debridement was done but patient died of sepsis.

Conclusion

Proximal femur replacement with modular stem implant has advantages over conventional hip implant in patients undergoing surgery after failure of internal fixation.

•

Failure of hip implant surgeries can be caused by various factors.

•

In management of an elderly patient with hip fractures, the aim is to ambulate patient.

•

Proximal femur replacement with modular stem implant has advantages over conventional hip implant.

Definitive Resection Arthroplasty of the Knee: A Surprisingly Viable Treatment to Manage Intractable Infection in Selected Patients

BACKGROUND

Resection arthroplasty of the hip is considered a viable option after multiple failed attempts to eradicate a prosthetic joint infection (PJI). However, much less information about resection arthroplasty of the knee is available. The goals of this study were to determine the success of infection eradication with a resection arthroplasty of the knee and subsequent functional outcomes in this group.

METHODS

We retrospectively identified 25 knees (23 patients) treated with resection arthroplasty of the knee for PJI performed at a single institution between 1974 and 2016. The mean age at resection arthroplasty was 65 years. The mean body mass index was 37 kg/m², and the mean Charleston Comorbidity Index was 5. Patients had a mean of 5 operations on the knee (mean of 3 operations for infection) before the resection arthroplasty. Failure to eradicate the infection was defined as any reoperation for infection. Clinical outcomes were assessed via ambulatory status, use of gait aids, and ongoing pain. The mean follow-up was 4 years.

RESULTS

At most recent follow-up, 84% (21 of 25) of knees were free of infection. Three patients had recurrent infection within the first year, and 1 patient had a late infection at 4 years postoperatively. However, only 1 patient required a subsequent amputation. Forty-five percent were community ambulators, 35% were household ambulators, and 20% were only able to transfer. All patients required knee bracing and assistive devices. Fifteen percent of patients were using long-term narcotics.

CONCLUSION

This large series demonstrates the results of selected use of resection arthroplasty as a treatment for recalcitrant periprosthetic knee infections that have failed multiple attempts to eradicate an ongoing PJI. The resection definitively solved the infection in 84% of patients. Functional results were variable but surprisingly good in some. All patients required bracing and assistive devices.

The Girdlestone situation: a historical essay

The eponymous term 'Girdlestone situation' originally referred to an excision of the femoral head in case of an acute pyogenic infection of the hip, described by Gathorne Robert Girdlestone in 1945. Over time the procedure and the indication to perform it have significantly changed. This article presents a short biography of Girdlestone with a concomitant report on investigating the evolution of the indication and technique of the Girdlestone situation from the first description up to contemporary literature.

Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty: An Analysis of 2,884 Cases

BACKGROUND

Postoperative infection remains a major challenge in revision total hip arthroplasty (THA) and revision total knee arthroplasty (TKA). Wound irrigation with dilute povidone-iodine (PI) solution has emerged as a simple, inexpensive, and potentially successful means of reducing postoperative infections. The aim of this study was to assess its effectiveness in reducing infection following revision THA and TKA in, to our knowledge, the largest revision cohort to date.

METHODS

Using our institution's total joint registry, we identified 1,402 revision THAs and 1,482 revision TKAs performed during the study period (2013, when the PI irrigation protocol was first implemented, to 2017). The PI lavage protocol was employed in 27% of the revision THA cases and 34% of the revision TKA cases; in the remaining cases, the protocol was not used. Demographics, comorbid conditions, underlying surgical diagnoses, and whether the revision was for a septic or an aseptic etiology were compared between the groups (use or no use of PI irrigation). Any reoperation due to infection, as assessed at 3 and 12 months following revision arthroplasty, was compared between the groups and propensity scores were calculated to account for differences in baseline characteristics between the groups.

RESULTS

After adjusting for baseline differences between the groups using the propensity-score weighted models, we found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received PI lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA.

CONCLUSIONS

PI wound lavage demonstrated no benefit in reducing any reoperation for infection following revision THA and TKA. Moreover, the trend toward higher rates for reoperation for infection among patients who received PI irrigation merit further consideration.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predicting Success of Two-Stage Exchange for Prosthetic Joint Infection Using C-Reactive Protein/Albumin Ratio

Two-stage exchange is most commonly used for treatment of prosthetic joint infections (PJI) but, this may fail to eradicate infections. C-reactive protein/albumin ratio (CAR) has been used to predict survival and operative success in other surgical subspecialties and so, we assess the association between CAR and reimplantation success during two-stage revision for PJI defined by the Musculoskeletal Infection Society following a primary total hip (THA) or knee (TKA) arthroplasty. From January, 2005 to December, 2015, two institutional databases were queried and patient demographics, antibiotic duration, C-reactive protein, and albumin were collected prior to reimplantation. Two-stage revisions were considered successful if patients were off of antibiotics and did not require a repeat surgery. CAR was available for 79 patients (34 hips and 46 knees) with 61 successful two-stage revisions and 18 failures. The average CAR for patients with successful reimplantation was 1.2 (0.2, 3.0) compared to 1.0 (0.4, 3.2) for treatment failure. However, this was not statistically significant (p=0.766). Therefore, CAR is not applicable in predicting the prognosis of two-stage revisions for PJI in total arthroplasty but other preoperative inflammatory-based prognostic scores should be explored.

Quality of life and health status after Girdlestone resection arthroplasty in patients with an infected total hip prosthesis

Introduction: The Girdlestone resection arthroplasty (GRA) is a salvage procedure for a recurrent or persistent prosthetic joint infection of the hip. This procedure negatively impacts the functional outcome and presumably also diminishes health status (HS) and quality of life (QOL). However, studies investigating the QOL after GRA are lacking. This cross-sectional study compares patients with a Girdlestone situation after an infected total hip prosthesis with a normative population with regard to HS and QOL.

Methods: Patients with a permanent GRA were suitable to be enrolled in the study. Subjects completed the World Health Organization Quality of life (WHOQOL-BREF) and the EuroQol 5 dimension 3 level version (EQ-5D-3L). Scores were compared with data from the normal population, from patients with a lower limb amputations and data from patients with a myocardial infarction.

Results: Sixty-three patients who underwent GRA between January 2000 and March 2017 completed the questionnaire. The median time between the GRA and competing the questionnaire was 48 months (4 -436). All WHOQOL-BREF domain scores were significantly lower in GRA patients compared to the normative data (p<0.001), patients with myocardial infarction or lower limb amputation. EQ-5D-3L results showed that HS was significantly impaired in GRA patients when compared to normative data (p<0.001) and also impaired when compared to data from lower limb amputations and myocardial infarctions.

Conclusion: HS and QOL scores in patients with a permanent Girdlestone situation after an infected hip prosthesis are significantly lower than Dutch normative scores. Patients with a permanent Girdlestone situation scored even lower on HS than patients with a lower limb amputation or a myocardial infarction.

Resection arthroplasty in radiation-induced osteonecrosis of the hip

PURPOSE

The purpose of this study was to evaluate the choice of appropriate surgical procedure through follow-up of postoperative results in patients with radiation-induced osteonecrosis of the hip.

MATERIALS AND METHODS

From January 1990 to December 2010, 25 patients underwent surgery for hip osteonecrosis after pelvic irradiation, for a total of 31 cases. The mean patient age was 61.6 years and the mean follow-up period was 60.4 months. There were 28 cases of primary total hip arthroplasty, three cases of primary resection arthroplasty, and six cases of secondary resection arthroplasty after total hip arthroplasty failure. The THA group was classified into two groups according to the period of operation: 1990 ∼ 2000 and 2001 ∼ 2010. THA and resection arthroplasty were compared retrospectively.

RESULTS

In the 16 cases of primary total hip arthroplasty (1990 ∼ 2000), 8 cases (50%) had a failed acetabular component. In 12 cases of primary total hip arthroplasty (2001 ∼ 2010), two cases (16.7%) had a failed acetabular component and two cases (16.7%) had an infection. Six cases underwent resection arthroplasty after total hip arthroplasty. There were no complications in the nine cases of resection arthroplasty. Seven of the nine cases (77.7%) had pain relief. The mean VAS scores of the resection arthroplasty group were lower than those of the total hip arthroplasty group at the time of the latest follow up (P = 0.04).

CONCLUSIONS

The failure rate of total hip arthroplasty used in radiation necrosis has decreased. Therefore, total hip arthroplasty should be the primary surgical method in patients with radiation-induced osteonecrosis of the hip. Resection arthroplasty is limited as first-line therapy due to functional problems. It use should be limited to pain control in low-demand elderly patients.

Management and outcome of the dislocated hip hemiarthroplasty

AIMS

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

PATIENTS AND METHODS

Of 3326 consecutive patients treated with hemiarthroplasty for fractured neck of femur, 46 (1.4%) sustained dislocations. Of the 46 dislocations, there were 37 female patients (80.4%) and nine male patients (19.6%) with a mean age of 83.8 years (66 to 100). Operative intervention for each, and subsequent dislocations, were recorded. The following outcome measures were recorded: dislocation; mortality up to one-year post-injury; additional surgery; residential status; mobility; and pain score at one year.

RESULTS

Of 43 dislocations, 30 (70%) occurred within one month and 42 (98%) occurred within three months of hip fracture surgery. Seven (16%) of these patients were treated with a single closed reduction and sustained no further dislocations. Four (9%) were treated with open reduction and experienced no further dislocations. Three (7%) hips were left dislocated and the remaining 32 (74%) patients required additional surgery of further closed reduction, revision, or excision arthroplasty. The one-year mortality rates for patients treated with two or fewer reductions (open or closed), successful revision arthroplasty, and excision arthroplasty were 3/14 (21%), 1/7 (14%), and 8/14 (57%) respectively. The only statistically significant difference in mortality was the difference between patients who did not sustain a dislocation and those who did and were treated by excision arthroplasty (p = 0.03). Patients treated by excision arthroplasty had the greatest reduction in mobility scores and highest pain scores. The excision arthroplasty group also included the greatest proportion of patients not able to mobilize and the smallest proportion of patients remaining in their own home.

CONCLUSION

Most dislocations of hemiarthroplasties of the hip occur within one month of surgery. Closed reduction is generally unsuccessful. For those patients with unsuccessful closed reduction, revision arthroplasty should be considered when possible, as this results in a better functional outcome with a lower mortality than excision arthroplasty.

A Devasting Course of an Iliopsoas Muscle Abscess Subsequently Leading to Septic Shock, Septic Hip Arthritis, and Extended Gluteal Soft Tissue Necroses in an Elderly Immunocompromised Patient with Multiple Carcinomas: A Case Report and Brief Review of Literature

BACKGROUND

A devasting course of Iliopsoas Muscle (IPM) abscess remains a challenging therapeutic problem.

METHODS

A 69-year-old polymorbid male had a history of multiple carcinomas and presented with advanced stage of septic shock due to a right IPM abscess which communicated with the right hip joint and subsequently led to septic hip arthritis accompanied with post-infectious right gluteal deep soft tissue necroses. Management of surgical treatment included abscess revision, coverage with the use of Long Head Biceps Femoris Muscle (LHBFM) 180° turnover flap, and creating a Girdlestone resection-arthroplasty.

RESULTS

After a duration of patient's hospitalization of six months that included the necessity of artificial respiration over two months accompanied with in summary 18 required surgical procedures, the patient could be recovered successfully regarding his polymorbidity and his low-demand claims in activities of daily living with his Girdlestone resection-arthroplasty.

CONCLUSION

Recovery of immunocompromised patients with those life-threatening situations can only be achieved by an interdisciplinary management. The LHBFM 180° turnover flap can be useful for filling off post-infectious deep soft tissue cavities communicating with the hip joint. The definitive Girdlestone resection-arthroplasty for treatment of septic hip arthritis is the method of choice for mobilization of elderly polymorbid patients with low demand claims in their activities of daily living.

Is Head and Neck Resection of the Femur (Girdlestone's Procedure) Still Relevant? Indications and Results About 24 Cases

Introduction

Head and neck resection of the femur was described by Girdlestone in 1928 in the treatment of coxalgia. Very invasive at the beginning, this intervention is much less so today, but the term of "Girdlestone's operation" or "Girdlestone's procedure" has remained in use. The reported results are controversial. In resource-limited countries, Girdlestone's procedure is often indicated for lack of a better one. In this context, we report the results of a series of 24 patients operated in a regional hospital (Ouahigouya, Burkina Faso) with the aim of showing that this technique remains valid and can be benefit.

Methods

This was a retrospective descriptive study of 24 patients who had benefited from the procedure for cervical fracture sequelae, failure of arthroplasty or osteosynthesis, or osteonecrosis. All were operated by posterolateral approach, under spinal anesthesia and followed for 5 years with evaluation of the anatomical and functional results using the rating of Postel and Merle d'Aubigné (PMA).

Results

All patients had Trendelenburg lameness with a mean shortening of 3.5 cm. They were all autonomous with walking aids and the PMA score ranged from 16 to 14. Discussion: although the results obtained are not excellent, they are relatively good and have allowed all our patients to recover an acceptable autonomy, compatible with certain independence in everyday life.

Conclusion

The Girdlestone's procedure cannot be a first intention indication, but retains a place in the therapeutic arsenal of certain affections of the hip.

A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review

BACKGROUND

A deep infection of the surgical site is reported in 0.7% of all cases of total hip arthroplasty (THA). This often leads to revision surgery that is invasive, painful and costly. A range of strategies is employed in NHS hospitals to reduce risk, yet no economic analysis has been undertaken to compare the value for money of competing prevention strategies.

OBJECTIVES

To compare the costs and health benefits of strategies that reduce the risk of deep infection following THA in NHS hospitals. To make recommendations to decision-makers about the cost-effectiveness of the alternatives.

DESIGN

The study comprised a systematic review and cost-effectiveness decision analysis.

SETTING

77,321 patients who had a primary hip arthroplasty in NHS hospitals in 2012.

INTERVENTIONS

Nine different treatment strategies including antibiotic prophylaxis, antibiotic-impregnated cement and ventilation systems used in the operating theatre.

MAIN OUTCOME MEASURES

Change in the number of deep infections, change in the total costs and change in the total health benefits in quality-adjusted life-years (QALYs).

DATA SOURCES

Literature searches using MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were undertaken to cover the period 1966-2012 to identify infection prevention strategies. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. Orthopaedic surgeons and infection prevention experts were also consulted.

REVIEW METHODS

English-language papers only. The selection of evidence was by two independent reviewers. Studies were included if they were interventions that reported THA-related deep surgical site infection (SSI) as an outcome. Mixed-treatment comparisons were made to produce estimates of the relative effects of competing infection control strategies.

RESULTS

Twelve studies, six randomised controlled trials and six observational studies, involving 123,788 total hip replacements (THRs) and nine infection control strategies, were identified. The quality of the evidence was judged against four categories developed by the National Institute for Health and Care Excellence Methods for Development of NICE Public Health Guidance ( http://publications.nice.org.uk/methods-for-the-development-of-nice-public-health-guidance-third-edition-pmg4 ), accessed March 2012. All evidence was found to fit the two highest categories of 1 and 2. Nine competing infection control interventions [treatments (Ts) 1-9] were used in a cohort simulation model of 77,321 patients who had a primary THR in 2012. Predictions were made for cases of deep infection and total costs, and QALY outcomes. Compared with a baseline of T1 (no systemic antibiotics, plain cement and conventional ventilation) all other treatment strategies reduced risk. T6 was the most effective (systemic antibiotics, antibiotic-impregnated cement and conventional ventilation) and prevented a further 1481 cases of deep infection, and led to the largest annual cost savings and the greatest gains to QALYs. The additional uses of laminar airflow and body exhaust suits indicate higher costs and worse health outcomes.

CONCLUSIONS

T6 is an optimal strategy for reducing the risk of SSI following THA. The other strategies that are commonly used among NHS hospitals lead to higher cost and worse QALY outcomes. Policy-makers, therefore, have an opportunity to save resources and improve health outcomes. The effects of laminar air flow and body exhaust suits might be further studied if policy-makers are to consider disinvesting in these technologies.

LIMITATIONS

A wide range of evidence sources was synthesised and there is large uncertainty in the conclusions.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and the Queensland Health Quality Improvement and Enhancement Programme (grant number 2008001769).

Evaluation of bone viability in patients after girdlestone arthroplasty: comparison of bone SPECT/CT and MRI

PURPOSE

To test the diagnostic performance of bone SPECT/CT and MRI for the evaluation of bone viability in patients after girdlestone-arthroplasty with histopathology used as gold standard.

MATERIALS AND METHODS

In this cross-sectional study, patients after girdlestone-arthroplasty were imaged with single-photon-emission-computed-tomography/computed-tomography (SPECT/CT) bone-scans using 99mTc-DPD. Additionally, 1.5 T MRI was performed with turbo-inversion-recovery-magnitude (TIRM), contrast-enhanced T1-fat sat (FS) and T1-mapping. All imaging was performed within 24 h prior to revision total-hip-arthroplasty in patients with a girdlestone-arthroplasty. In each patient, four standardized bone-tissue-biopsies (14 patients) were taken intraoperatively at the remaining acetabulum superior/inferior and trochanter major/minor. Histopathological evaluation of bone samples regarding bone viability was used as gold standard.

RESULTS

A total of 56 bone-segments were analysed and classified as vital (n = 39) or nonvital (n = 17) by histopathology. Mineral/late-phase SPECT/CT showed a high sensitivity (90%) and specificity (94%) to distinguish viable and nonviable bone tissue. TIRM (sensitivity 87%, specificity 88%) and contrast-enhanced T1-FS (sensitivity 90%, specificity 88%) also achieved a high sensitivity and specificity. T1-mapping achieved the lowest values (sensitivity 82%, specificity 82%). False positive results in SPECT/CT and MRI resulted from small bone fragments close to metal artefacts.

CONCLUSIONS

Both bone SPECT/CT and MRI allow a reliable differentiation between viable and nonviable bone tissue in patients after girdlestone arthroplasty. The findings of this study could also be relevant for the evaluation of bone viability in the context of avascular bone necrosis.

Fracture Diaphyseal Femur in a Case of Ipsilateral Excision Arthroplasty of Hip: Report of Two Cases with Description of an Unusual Injury Pattern, Mechanism, and Clinical Decision-making in Management

INTRODUCTION

Although fracture diaphyseal femur is commonly seen in orthopedic practice, its association with ipsilateral resection arthroplasty of hip/pseudarthrosis of neck is rare. The technique of excision arthroplasty has undergone modification with emphasis on preserving as much bone as possible. However, it is not always possible to preserve bone while removing the earlier prosthesis and cement. This often leads to extensive proximal bone loss. Associated ipsilateral fracture femur presents a unique scenario. Till date, only one case report is published highlighting its surgical management.

CASE REPORT

We report two cases of diaphyseal fracture femur associated with resection arthroplasty of hip at subtrochanteric level with greater trochanter as a separate fragment (Case 1) and other with pseudarthrosis of the neck of femur with intact greater trochanter (Case 2). The first case was operated with surface fixation, whereas the second was operated with closed antegrade intramedullary nail.

CONCLUSION

Decision-making and formulating treatment plan includes taking various factors into account such as level of resection arthroplasty of hip/pseudarthrosis of neck, status of greater trochanter (intact or separate fragment), osteoporosis, and post-operative ambulation and rehabilitation. In this report, we highlight the unusual occurrence, probable mechanism of injury, risk factors for fracture, and decision-making in the surgical management of such a condition.

Infected Iliac Pseudoaneurysm after Cardiac Catheterization Complicated by Girdlestone Pseudoarthroplasty for Recurrent Infection of Hip Prosthesis

We report a massive infected pseudoaneurysm of the right external iliac artery in the setting of Girdlestone pseudoarthroplasty (GSA) for chronic infection. Around the time of her GSA, the patient underwent cardiac catheterization with resultant pseudoaneurysm formation. Infection was likely due to spread from her previous chronic infection. Delay in presentation occurred due to attribution of her symptoms to her GSA. The patient underwent ligation of the right external iliac artery and hip disarticulation and was discharged on antibiotics. At follow-up, she had significantly reduced pain. Although vascular complications from orthopedic procedures are well described, this case seems to have been caused by secondary infection of her iatrogenic external iliac artery pseudoaneurysm.

Modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov external fixator as a salvage method in the management of severely infected total hip replacement

BACKGROUND

Resection arthroplasty or hip arthrodesis after total hip replacement (THR) can be used to salvage the limb in case with deep infection and severe bone loss. The Ilizarov fixator provides stability, axial correction, weight-bearing and good fusion rates.

MATERIALS AND METHODS

We retrospectively assessed the outcomes of 37 patients with severe periprosthetic infection after THR treated between 1999 and 2011. The treatment included implant removal, debridement and a modified Girdestone arthroplasty (29 cases) or hip arthrodesis (seven cases) using the Ilizarov fixator. The Ilizarov fixation continued from 45 to 50 days in the modified arthroplasty group and 90 days in the arthrodesis group. One case was treated using the conventional resection arthroplasty bilaterally.

RESULTS

Eighteen months after treatment, infection control was seen in 97.3% cases. Six hips were fused as one patient died in this group. Limb length discrepancy (LLD) averaged 5.5 cm. The Harris hip score ranged from 35 to 92 points. Hip joint motion ranged from 10° to 30° in the modified arthroplasty group. All subjects could walk independently or using support aids. No subluxation or LLD progression was observed.

CONCLUSION

The modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov apparatus results in sufficient ability for ambulation and good infection control in cases of failed THR associated with severe infection.

Titanium-Based Hip Stems with Drug Delivery Functionality through Additive Manufacturing

Postoperative infections are a major concern in patients that receive implants. These infections generally occur in areas with poor blood flow and pathogens do not always respond to antibiotic treatment. With the latest developments in nanotechnology, the incorporation of antibiotics into prosthetic implants may soon become a standard procedure. The success will, however, depend on the ability to control the release of antibiotics at concentrations high enough to prevent the development of antibiotic-resistant strains. Through additive manufacturing, antibiotics can be incorporated into cementless femoral stems to produce prosthetic devices with antimicrobial properties. With the emerging increase in resistance to antibiotics, the incorporation of antimicrobial compounds other than antibiotics, preferably drugs with a broader spectrum of antimicrobial activity, will have to be explored. This review highlights the microorganisms associated with total hip arthroplasty (THA), discusses the advantages and disadvantages of the latest materials used in hip implants, compares different antimicrobial agents that could be incorporated, and addresses novel ideas for future research.

Complication, Survival, and Reoperation Rates Following Girdlestone Resection Arthroplasty

Failed hip arthroplasty patients unsuitable for reimplantation may be offered Girdlestone resection arthroplasty (GRA). The purpose of this study was to detail complication and failure rates following GRA. Our results show that 66% (25/38), 34% (13/38), and 76% (29/38) of GRA patients experienced minor, major, and overall complications, respectively. Within 90 days of surgery, three patients required additional surgery and four died. Reoperation or death occurred an average of 26.3 (SD=3.5) and 55.6 (SD=76) months after surgery, respectively. Male gender and increasing comorbidity significantly predicted higher reoperation and mortality rates, P=0.01 and P=0.04, respectively. Complication and mortality rates following GRA are among the highest reported succeeding elective hip surgery for non-traumatic etiology.

Two-stage revision of an infected total hip arthroplasty: a follow-up of 136 patients

BACKGROUND AND PURPOSE

Periprosthetic infection of a total hip arthroplasty (THA) is commonly treated with a two-stage revision procedure. After resection of the infected THA and placement of a cement spacer loaded with antibiotics, a THA is inserted at a second procedure to restore hip function and mobility. Revision surgery carries a significant risk of complications. This study focuses on hip function, rate of complications and reinfection after two-stage revision surgery for an infected THA.

PATIENTS AND METHODS

From January 1996 to April 2010, 136 patients underwent revision surgery after removal of an infected THA. Follow-up ranged from 2 years to more than 15 years. Hip function was evaluated using the modified Harris Hip Score (mHHS) and the Hip disability and Osteoarthritis Outcome Score (HOOS). Visual Analogue Scale (VAS) measured pain. Annual follow-up included radiographs of the affected hip and blood sampling for inflammatory parameters.

RESULTS

After revision surgery, average mHHS was 63% and average HOOS was 54%. VAS pain averaged 26.8 on a 100-point scale and 40% of patients had no pain. Prosthesis-related complications unrelated to sepsis occurred in 32%. Most common were periprosthetic fractures, leg length discrepancy and dislocation. Reinfection occurred in 13% of these patients and Coagulase Negative Staphylococcus (CNS) was isolated in 67%.

CONCLUSION

Two-stage evision surgery is an accepted treatment for infected THAs. However, complications are common and hip function afterwards is modest. As previous studies have shown, CNS is an important microorganism in reinfection.

Is prosthesis retention effective for chronic infections in hip arthroplasties? A systematic literature review

The success rate of prosthesis removal as the standard approach to manage chronic infection in hip arthroplasties (HA) is 80-90 %. The effectiveness of prosthesis retention, with or without surgical debridement, to treat patients with chronic HA infection (symptom duration of more than 4 weeks) has not been well established, whereas this strategy is sometimes used in clinical practice. This study aimed to explore the cumulative incidence of failure of chronic HA infections treated with prosthesis retention, with or without debridement. A systematic literature review was conducted in accordance with the methods described in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies concerning patients with chronically infected HA treated with prosthesis retention were included. The primary outcome was the cumulative risk of failure. We searched the MEDLINE, Embase, and Cochrane databases up to April 2014. The database searches provided a total of 1,213 studies for potential inclusion in the review. Six relevant studies were finally identified, corresponding to 29 patients included. Their treatments consisted of prosthesis retention with debridement. This strategy failed for 14 out of these 29 patients after a 1-year follow-up. The failure rate of the prosthesis retention approach associated to debridement for chronic infection in HA is 48.3 % in this review. Debridement and prosthesis retention in association with prolonged antimicrobial treatment may be an advantageous alternative to arthroplasty exchange for frail patients. The difficulty in finding relevant studies illustrates the challenges of interpreting the existing literature for the management of chronic prosthetic joint infection (PJI).

Clinical outcome following conversion of Girdlestone's resection arthroplasty to total hip replacement: a retrospective matched case-control study

A total of 31 patients, (20 women, 11 men; mean age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone resection-arthroplasty (RA) to a total hip replacement (THR) were compared with 93 patients, (60 women, 33 men; mean age 63.4 years old; 20 to 89), who had revision THR surgery for aseptic loosening in a retrospective matched case-control study. Age, gender and the extent of the pre-operative bone defect were similar in all patients. Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the control group (p = 0.01 and 0.003, respectively) and pre-operative leg length discrepancy (LLD) was greater in the RA group (p < 0.001). The post-operative clinical outcome was similar in both groups except for mean post-operative LLD, which was greater in the study group (p = 0.003). There was a significant interaction effect for LLD in the study group (p < 0.001). A two-way analysis of variance showed that clinical outcome depended on patient age (patients older than 70 years old had worse pre-operative pain, p = 0.017) or bone defect (patients with a large acetabular bone defect had higher LLD, p = 0.006, worse post-operative function p = 0.009 and range of movement, p = 0.005), irrespective of the group. Despite major acetabular and femoral bone defects requiring complex surgical reconstruction techniques, THR after RA shows a clinical outcome similar to those obtained in aseptic revision surgery for hips with similar sized bone defects.

[Treatment of a recalcitrant hip infection with a vastus lateralis muscle flap]

BACKGROUND

Recalcitrant hip infection after arthroplasty presents a reconstructive challenge to orthopedic surgeons. The aim of this study is to evaluate the results with a vastus lateralis muscle flap used to treat these recalcitrant hip infections in our Department.

MATERIAL AND METHODS

A retrospective descriptive study was conducted on five patients with deep hip infections by transposition of the vastus lateralis muscle flap. Average age: 70.5 years. Mean follow-up: 30 months (range, 25-34 months). All patients had previously undergone other major surgical procedures (mean of 3.7 previous procedures). All had multiple microbial infections before surgery. The pathogens involved using cultures of the fistula, the outcome of the wound and laboratory results, including C-reactive protein (CRP), were analysed.

RESULTS

Healing was achieved in the five patients who underwent surgery without requiring any further procedures or inflammatory signs of infection. CRP returned to normal one month after surgery, and there was no morbidity or mortality related to surgical technique.

CONCLUSION

In our experience, the vastus lateralis muscle flap as a treatment for recalcitrant deep infection after arthroplasty has presented good results, provided there is appropriate antibiotic therapy and surgical debridement, thus achieving wound healing and a return to normal of the CRP.

Girdlestone procedure: when and why

Girdlestone is one of the options for treating an infected hip arthroplasty (along with isolated antibiotics, debridement, and one or two-stage exchange). The choice must be based on a list of previous considerations. RESULTS OF GIRDLESTONE: Major differences among different series are reported in literature: from 13% to 83% of patients are satisfied with the result. Healing of infection is attained in 80% to 100% of patients, but figures are worse in special subsets (rheumatoid arthritis, enterococcal and methicillin-resistant infections, or when cement is retained). Pain is reported as severe in 16% to 33% of patients, moderate in 24% to 53% and mild in 76%, while only some authors refer to "satisfactory pain relief". Up to 45% of geriatric patients are unable to walk and only 29% walk independently. The literature reports Harris Hip scores from 25 to 64. INDICATIONS FOR GIRDLESTONE: Absolute indications: non-ambulatory patients because of other problems or diseases, and impossible reimplantation (2nd-stage surgery) (unacceptable anaesthetic or surgical risk, technical difficulties, patient rejection). RELATIVE INDICATIONS: Dementia (risk of dislocation vs. severely reduced walking ability), immunocompromise (up to what degree of immune impairment do we accept to take the risk?), intravenous drug abuse (how can you prove it?).

Ipsilateral diaphyseal femur fracture after resection arthroplasty

Resection arthroplasty of the hip is most commonly used for recalcitrant infections in the setting of prior hemiarthroplasty and total hip arthroplasty. Reported complications of this procedure include shortening of the extremity and ambulation difficulties requiring assistive devices. We report a case of an unusual finding of an ipsilateral femoral shaft fracture after a ground level fall 4 months after a resection arthroplasty for a septic hip. A closed reduction with internal fixation using an intramedullary nail was performed, and 3 months postoperatively, the patient was ambulating with device assistance.

Total hip arthroplasty after excision arthroplasty: indications and limits

We reviewed performed a retrospective review of our series of excision arthroplasty patients and identified 16 patients who had undergone the procedure for sepsis, and who we had subsequently subjected to revision to a total hip arthroplasty (THA). Mean follow-up was 96 +/- 15 months. There was a significant reduction in limb length discrepancy and a marked improvement in walking capability. Range of movement improved most in patients under 65 years of age. Patient selection is critical, because THA after excision arthroplasty is complex, and may have less satisfactory results primary surgery.

Surgical therapy of hip-joint empyema. Is the Girdlestone arthroplasty still up to date?

PURPOSE

Hip-joint empyema is a severe local infection that can cause general illness and, in the worst-case scenario, death by septic complications. For severe hip-joint infections, the Girdlestone arthroplasty has been an established treatment option for many decades. We describe functional midterm results after treatment of haematological and postoperative hip-joint infections.

METHODS

From 2000 to 2010, 24 patients underwent surgical treatment for 27 hip-joint empyemas. The surgical procedures included radical debridement, implantation of local antibiotic beads and soft tissue management. Besides clinical, laboratory and imaging parameters, we analysed the Harris hip score (HHS).

RESULTS

Twenty-three patients (26 hips) were followed up after a mean of 30 (3.1-126.8) months. The study group consists of 12 men and 11 women, with an average height of 1.71 m, weight of 84.7 kg and body mass index (BMI) of 28.6 kg/m(2). Hip-joint empyema was due to haematological septic spread in eight patients, surgery related in 12 hips and other causes in six cases. One patient died due to septic complications during the hospital stay. Intraoperative bacterial culture was positive in 50%, with Staphylococcus aureus as the most common organism (n = 11). Average hospital stay was 35 days. HHS significantly improved from 18.2 preoperatively to 47.8 at follow-up. Functional results were mainly poor, but pain relief increased significantly. The infection control rate was 96% with four (15%) complications.

CONCLUSION

Resection arthroplasty by Girdlestone is able to control infection in most cases with an acceptable complication rate but poor functional results. In conclusion, the Girdlestone arthroplasty still is an essential surgical strategy for treating hip-joint empyema in cases in which functional outcome is of lesser priority.