Periprosthetic joint infections in femoral neck fracture patients treated with hemiarthroplasty – should we use antibiotic-loaded bone cement?

BACKGROUND

Hemiarthroplasty is the most common treatment in elderly patients with displaced intra-capsular femoral neck fracture (FNF). Prosthetic joint infection (PJI) is one of the most feared and frequent complications post-surgery because of the frail health status of these patients and the need for fast track surgery. Therefore, priorities should lie in effective preventive strategies to mitigate this burden.

AIM

To determine how much the implementation of the routine use of antibiotic-loaded bone cement (ALBC) as a relatively easy-to-apply amendment to the surgical practice reduces the infection rate in our hemiarthroplasty cohort.

METHODS

We retrospectively assessed all demographic, health status and treatment-related data of our FNF patients undergoing cemented hemiarthroplasty in the period from 2011 to 2017; 241 patients were further analyzed after exclusion of patients with cancer-related sequelae and those who died before the end of the 1-year observation period. The PJI rate as diagnosed on basis of the Musculoskeletal Infection Society (MSIS) criteria 2011 was determined for each included patient and compared in function of the bone cement used for hip stem fixation. Patients were split into a group receiving a plain bone cement in the period from January 2011 to June 2013 (non-ALBC group) and into a group receiving an ALBC in the period July 2013 to December 2017 (ALBC group). Data analysis was performed with statistical software. We further calculated the cost-efficacy of the implementation of routine use of ALBC in the second group balancing the in-hospital infection related treatment costs with the extra costs of use of ALBC.

RESULTS

In total 241 FNF patients who received cemented hemiarthroplasty in the period from January 2011 to January 2017 were eligible for inclusion in this retrospective study. There were 8 PJI cases identified in the ALBC group among n = 94 patients, whereas 28 PJI cases were observed in the non-ALBC group among n = 147 patients. The statistical analysis showed an infection risk reduction of 55.3% (in particular due to the avoidance of chronic delayed infections) in the ALBC group (95%CI: 6.2%-78.7%; P = 0.0025). The cost-evaluation analysis demonstrated a considerable cost saving of 3.500 € per patient, related to the implementation of routine use of ALBC in this group.

CONCLUSION

Use of ALBC is a potent infection preventive factor in FNF patients receiving cemented hemiarthroplasties. It was further found to be highly cost-effective.

In vitro chondral culture under compression and shear stimuli. From mesenchymal stem cells to hyaline cartilage

INTRODUCTION

The in vitro creation of hyaline joint cartilage is a challenge since, to date, the ex vivo synthesis of a structured tissue with the same biomechanical and histological properties of the joint cartilage has not been achieved. To simulate the physiological conditions we have designed an in vitro culture system that reproduces joint movement.

MATERIAL AND METHOD

We have developed a cell culture bioreactor that prints a mechanical stimulus on an elastin matrix, in which mesenchymal stem cells (MSC) are embedded. The first phase of study corresponds to the development of a bioreactor for hyaline cartilage culture and the verification of cell viability in the elastin matrix in the absence of stimulus. The second phase of the study includes the MSC culture under mechanical stimulus and the analysis of the resulting tissue.

RESULTS

After culture under mechanical stimulation we did not obtain hyaline tissue due to lack of cellularity and matrix destructuring.

CONCLUSION

The stimulus pattern used has not been effective in generating hyaline cartilage, so other combinations should be explored in future research.

Periprosthetic infection in elderly patients treated with hemiarthroplasty of the hip following intracapsular fracture. Should we use antibiotic-loaded bone cement?

INTRODUCTION

Prosthetic infections are a potentially devastating complication, especially in elderly patients. Antibiotic-loaded bone cement has been used both as a treatment and prophylaxis in prosthetic infection, and its use is not well documented in the prophylaxis of infection in patients who have suffered a hip fracture.

MATERIAL

A retrospective descriptive was performed. The data were obtained from all the patients who underwent hip hemiarthroplasty due to a subcapital fracture between 2011 and 2017 (N=241). An epidemiological study of the patients studied was carried out. We analysed the incidence of periprosthetic infection in the groups treated with cement without antibiotic and antibiotic-loaded bone cement, as well as the protective effect of the antibiotic-loaded bone cement. At the same time, a pilot cost analysis study was carried out.

RESULTS

In the group that received antibiotic-loaded bone cement (n=94) there were 8 infections (8%), while in the group with cement without antibiotic (n=147) there were 28 infections (19%). The odds ratio (OR) was calculated, showing a 55.3% reduction in the risk of developing late infection in the group that received cement with antibiotic (95% CI: 6.2-78.7%, P=.0025). The use of antibiotic-loaded bone cement led to significant cost savings per patient.

CONCLUSIONS

The use of antibiotic-loaded bone cement is a protective factor in the development of late infection after hip hemiarthroplasty surgery in elderly patients with hip fracture.

[Total knee arthroplasty infection, what is the best strategy for better functional outcomes?]

INTRODUCTION

Surgical strategy in dealing with periprosthetic knee infections remains controversial. The goals of treatment are to eradicate infection, improve pain and joint function. Surgical management includes implant debridement and retention, prosthetic replacement in one-time, or two-stage replacement. This latest surgical strategy is considered the «gold standard», reaching healing rates up to 80%-100%, although little has been published about functional results.

MATERIAL AND METHODS

Retrospective study of 65 patients with periprosthetic knee infection. In 20 patients a replacement was made in a time and in 45 patients were in two stages. Pre- and post-operative evaluation with the modified HSS scale. All patients were treated with intravenous antibiotherapy, we evaluated the analytical and clinical response to confirm the eradication or not of the infection.

RESULTS

The infection was resolved in 39 out of 65 patients, 12 in the replacement group in a time and 27 for the two-stages group. No significant difference between the groups in relation to healing or functional result. However, there is a statistically significant difference between those patients who received oral antibiotic treatment prior to diagnosis and those who did not.

CONCLUSIONS

The healing rate is similarly treated with replacement in a time and replacement in two times. We were unable to demonstrate superiority in the functional results between the two groups.

Intracapsular hip fractures in the elderly. Do we know what is important?

BACKGROUND

Hip fractures in the elderly are a common reason for admission to the department of orthopaedic surgery, this condition asks an important part of health resources and is associated with high levels of co-morbidity and mortality. Many improvements have been introduced in the treatment of these patients, preoperative regional analgesia, intensive physical therapy, interdisciplinary care program; but still remain unresolved gaps. The aim of this study is to document the natural history of early versus delayed surgical intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge.

METHODS

A sample of 499 patients admitted in our Institution was prospectively reviewed between February 2008 and February 2013. Preoperatively characteristics and functional data were assessed in relation with time to surgery (focused on mortality and ability to walk at first year).

RESULTS

The ability to walk and activities of daily living (functional results) were not associated with surgical delays (surgery before 24h from admission, surgery among 24h and 72h from admission and surgery later than 72h). However, ASA class, Parkinson disease and age were significantly associated with poor functional results. In the same way, mortality at 1year was not associated with time to surgery, but ASA class was associated with significant risk factor of 1 year-mortality.

CONCLUSIONS

ASA class, Parkinson disease and age are independent predictor of poor functional outcomes after intracapsular hip fracture. In addition, ASA class is an independent predictor of mortality. Patients with poor functional status before fracture and older than 75 years would benefit from geriatric and rehabilitation intervention immediately after surgery.

Case report of early aseptic loosening of total hip arthroplasty in monostotic paget disease, a diagnostic challenge

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Paget disease of bone can lead with severe bone destruction.

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Altered bone metabolism in patients with arthroplasties has a difficult diagnosis.

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We propose laboratory studies when severe boen destruction is seen in radiological images from hip implants.

Paget’s disease of bone is a localised chronic osteopathy which produces bone deformities, bone hypervascularity, structural weakness and altered joint biomechanics. Although radiological diagnosis of Paget's disease of bone is usually straightforward, monostotic cases may potentially raise specific problems which require invasive and expensive procedures such as bone biopsies. The pelvis and upper femur are frequently affected, resulting in disabling hip disease that may require total hip arthroplasty. We report a case of Paget disease of bone in an 84-year-old woman, which was initially identified as avascular necrosis of the hip, reason for which she underwent total hip arthroplasty. During follow up, the patient complained about hip pain and in a few months she was not able to walk because of an early loosening with bone destruction. Radiological and laboratory exams were carried out with normal results except for alkaline phosphatase (AP). After treatment with biphosphonates hip pain relieved but hip reconstruction was not possible. In this paper we present an early aseptic loosening of hip arthroplasty due to monostotic Paget’s disease of bone, a rare ethiology of loosening which poses particular diagnostic difficulties prompting an excessive use of excisional biopsies.

Stoppa approach, an alternative for total hip arthroplasty in an intra-pelvic cup

Removal of an acetabular prosthesis that has migrated into the pelvis can be hazardous. We describe the preoperative planning and the surgical procedure for removing a severely displaced acetabular component in one patient and outline our recommendation for the use of Stoppa approach because it has advantages of simple dissection, a low complication rate, and may help in preventing life-threatening problems.