Is there a role of calprotectin testing in the diagnosis of surgical site infections after total hip and knee arthroplasty? A preliminary study

BACKGROUND

Recent studies have revealed the usefulness of synovial calprotectin (CLP) in diagnosing chronic periprosthetic joint infections (PJIs). However, there is still a lack of evidence to support the use of serum CLP in the diagnosis of early PJIs and surgical site infections (SSIs) after total joint arthroplasties (TJAs).

OBJECTIVES

The primary aim of this study is to investigate the standard kinetics of CLP concentrations in the blood during the very early postoperative period after non-complicated total hip arthroplasty (THA) and total knee arthroplasty (TKA). The secondary aim was to perform a preliminary comparison of CLP concentrations between non-infected patients and patients with recognized SSIs.

MATERIAL AND METHODS

A total of 64 consecutive patients who underwent primary THA and TKA were included in this prospective research. Sixty patients (30 THA and 30 TKA) were scheduled to determine the standard shape of the blood CLP curve and the expected concentrations during the first 5 postoperative days after non-complicated TJAs. In 4 additonal patients, early SSI was confirmed, and they were included in a separate SSI subgroup.

RESULTS

Calprotectin demonstrated a linear increase during the first 5 postoperative days. Statistically significant differences in CLP concentrations between non-infected cases and SSIs were not observed. The preoperative median results with interquartile range (Q1-Q3) were 0.52 (0.39-0.64) mg/dL and 0.5 (0.47-0.52) mg/dL (p = 0.77), while post operation they were as follows: on postoperative day 1: 0.88 (0.53-1.3) mg/dL and 0.86 (0.62-1.1) mg/dL (p = 0.84), on postoperative day 3: 1.77 (1.29-2.08) mg/dL and 1.85 (1.70-1.95) mg/dL (p = 0.72), and on postoperative day 5: 2.32 (1.79-2.67) mg/dL and 2.56 (2.25-2.83) mg/dL (p = 0.55), respectively.

CONCLUSION

Serial CLP measurements during the early postoperative period revealed a linear (statistically significant) increase in concentration to postoperative day 5 without an evident point of decrease. A significant difference in median values and the course of curve patterns between the non-complicated and SSI groups was not observed.

Automated patellar height assessment on high-resolution radiographs with a novel deep learning-based approach

BACKGROUND

Artificial intelligence and deep learning have shown promising results in medical imaging and interpreting radiographs. Moreover, medical community shows a gaining interest in automating routine diagnostics issues and orthopedic measurements.

AIM

To verify the accuracy of automated patellar height assessment using deep learning-based bone segmentation and detection approach on high resolution radiographs.

METHODS

218 Lateral knee radiographs were included in the analysis. 82 radiographs were utilized for training and 10 other radiographs for validation of a U-Net neural network to achieve required Dice score. 92 other radiographs were used for automatic (U-Net) and manual measurements of the patellar height, quantified by Caton-Deschamps (CD) and Blackburne-Peel (BP) indexes. The detection of required bones regions on high-resolution images was done using a You Only Look Once (YOLO) neural network. The agreement between manual and automatic measurements was calculated using the interclass correlation coefficient (ICC) and the standard error for single measurement (SEM). To check U-Net's generalization the segmentation accuracy on the test set was also calculated.

RESULTS

Proximal tibia and patella was segmented with accuracy 95.9% (Dice score) by U-Net neural network on lateral knee subimages automatically detected by the YOLO network (mean Average Precision mAP greater than 0.96). The mean values of CD and BP indexes calculated by orthopedic surgeons (R#1 and R#2) was 0.93 (± 0.19) and 0.89 (± 0.19) for CD and 0.80 (± 0.17) and 0.78 (± 0.17) for BP. Automatic measurements performed by our algorithm for CD and BP indexes were 0.92 (± 0.21) and 0.75 (± 0.19), respectively. Excellent agreement between the orthopedic surgeons’ measurements and results of the algorithm has been achieved (ICC > 0.75, SEM < 0.014).

CONCLUSION

Automatic patellar height assessment can be achieved on high-resolution radiographs with the required accuracy. Determining patellar end-points and the joint line-fitting to the proximal tibia joint surface allows for accurate CD and BP index calculations. The obtained results indicate that this approach can be valuable tool in a medical practice.

Lateral or Medial Parapatellar Surgical Approach to the Valgus Osteoarthritic Knee? A Retrospective Single-Center Study

Aims: Total knee arthroplasty in patients with fixed valgus deformity is a demanding procedure. The aim of this study was to compare the clinical results of using the lateral approach [LA] versus the medial approach [MA] in the treatment of fixed valgus knee deformities. Methods: This single-center study compared the results of 143 consecutive patients with fixed valgus deformity (mean 21.55° valgus, mean age 68.2 years) undergoing LA Total Knee Arthroplasty [TKA] to 50 patients (mean 16.58° valgus, mean age 67.2 years) undergoing MA TKA. The mean follow-up period was 5.1 years (2−10 years). Data was collected from operative notes, routine postoperative visits, and radiological findings. Apart from a radiological evaluation, patients were clinically assessed both pre- and postoperatively using the Knee Society Score [KSS]. Descriptive statistics together with the Kolmogorov-Smirnov test, the Student’s t-test for independent samples, and the Mann-Whitney U test were used. The level of significance in this study was α = 0.05. Results: In the LA group, the KSS Knee was significantly higher than in the MA group [85.31 vs. 77.42, respectively, p-value < 0.001]. The difference was also in the KSS total but with no statistical significance [155.17 vs. 149.22, p-value 0.087]. The surgery time in the LA group was shorter than in the MA group [81 vs. 91 min, respectively, p-value—0.002]. The complication rate after surgery was higher in the MA group than in the LA group (14% vs. 9%, respectively). Conclusions: The lateral approach is a good alternative to the standard medial parapatellar approach in the treatment of fixed valgus knee deformities. A higher postoperative KSS Knee, shorter surgery time, and similar complication rate make the lateral approach a valuable option for treating patients with osteoarthritis and fixed valgus knee deformity.

Efficacy of intravenous tranexamic acid administration in revision hip arthroplasty

BACKGROUND

This study aimed to evaluate the efficiency of constant dose intravenous administration of tranexamic acid (TXA) in reducing postoperative blood loss, hemoglobin (Hb) concentration, and the number of transfusions in revision hip arthroplasty (RHA).

METHODS

The study included 145 consecutive patients who had undergone RHA: a TXA group (75 patients) who received two doses of TXA (1.0 g 15 min before skin incision and 1.0 g during wound closure) and a no-TXA group (70 patients). Percentage blood loss and quantitative blood loss were calculated.

RESULTS

The percentage blood loss (23.82 ± 10.6% vs. 39.17 ± 15.1%; P < 0.001), Hb drop (2.9 ± 1.14 g/dL vs. 4.22 ± 1.4 g/dL; P < 0.001), and total blood loss (1030 ± 477 mL vs. 1736 ± 761 mL; P < 0.001) were significantly lower in the TXA group than in the no-TXA group on postoperative day 1. Percentage blood loss (37.5 ± 10.4% vs. 43.1 ± 12.5%; P < 0.01), Hb drop (4.64 ± 1.5 g/dL vs. 5.22 ± 1.6 g/dL; P < 0.01) and total blood loss (1639 ± 543 mL vs. 1908 ± 681 mL; P = 0.02) were significantly lower in the TXA group than in the no-TXA group on the 5th postoperative day. The blood transfusion requirements were lower in the TXA group than those in the no-TXA group (30.7% vs. 71.4% of patients; P < 0.001), with a lower transfusion per patient ratio of 0.55 in the TXA group and 1.4 in the no-TXA group. No postoperative complications were associated with TXA administration, including deep-vein thrombosis and pulmonary embolism.

CONCLUSION

Administration of TXA is an effective method to reduce perioperative blood loss, Hb drop and the number of transfusions in RHA.

Elevated plasma D-dimer concentration has higher efficacy for the diagnosis of periprosthetic joint infection of the knee than of the hip-A single-center, retrospective study

The aim of this study is to evaluate the value of D-dimers in the diagnosis of periprosthetic joint infection (PJI). The analysis was performed for revision total hip (rTHA) and revision total knee arthroplasty (rTKA) together and separately with two thresholds, one calculated by statistical methods and the second adopted from the ICM 2018 definition. The study group comprised 133 patients who underwent rTHA or rTKA: 68 patients diagnosed according to the ICM 2018 definition (PJI group) and 65 with aseptic implant loosening, instability, malposition, or implant failure with the exclusion of infection (aseptic revision total joint arthroplasty or arTJA group). Mean D-dimer concentrations were 0.36 ± 0.25 μg/ml in the arTJA group and 0.87 ± 0.78 μg/ml in the PJI group (p < .001). For rTHA and rTKA together, the sensitivity and specificity of the evaluation were 75% and 73.8% according to the calculated cut-off value (0.45 μg/ml), and 33.8% and 95.4% based on the ICM 2018 threshold (0.85 μg/ml). Separately, for rTHA, sensitivity and specificity were 62.5% and 62.1% for the calculated value (0.43 μg/ml) and 6.3% and 96.6% for the ICM 2018 threshold; for rTKA, sensitivity was 86.1% and specificity was 88.9% for the calculated threshold (0.48 μg/ml) and 58.3% and 94.4% for the ICM 2018 value. Our findings indicate that plasma D-dimers have potential as markers of knee PJI, but moderate to low value for hip PJI.

Ultrasound frequency of sonication applied in microbiological diagnostics has a major impact on viability of bacteria causing PJI

OBJECTIVES

Sonication of explanted prosthesis constitutes an element of microbiological diagnostics. The aim of performing this procedure is to remove biofilm and to increase sensitivity of diagnostics. Ultrasound used in medical purposes are low-frequency and low-intensity. With this wide range of frequency which can be used in sonication process it is necessary to find the golden mean between biofilm dislodging and planktonic bacteria sparing.

MATERIALS AND METHODS

The aim of this study was to determine the least harming low-intensity ultrasound frequency (35 kHz, 40 kHz or 53 kHz) used during sonication process with other parameters constant. Four bacteria species were examined: S. aureus, E. faecalis, E. coli, K. pneumoniae. Number of microbiological studies (n) for each group (g) counted 40 specimens (based on scheme 1 bacteria type - 4 groups, 40 studies each).

RESULTS

A detailed analysis of gathered data was conducted. Based on study findings following conclusions were drawn. Sonication has a significant and negative impact on survival of sonicated planktonic bacteria. Part of bacteria in planktonic state are damaged/killed by ultrasound, which is demonstrated by lower CFU count in sonicated samples versus control group.

CONCLUSIONS

Optimal ultrasound frequencies for sonication of S. aureus, P. aeruginosa and E. coli are 35 kHz and 40 kHz. Ultrasound frequencies used in sonication process (35 kHz, 40 kHz, 53 kHz) of E. coli showed same impact on bacteria survival. It is crucial to perform further assessment of ultrasound parameters on clinical effects of sonication used in PJI diagnostics.

Total knee arthroplasty with simultaneous tibial shaft osteotomy in patient with multiple hereditary osteochondromas and multiaxial limb deformity - a case report

BACKGROUND

Hereditary multiple osteochondromas (hereditary multiple exostoses, HME) is a rare genetic disease characterized by the development of benign osteocartilaginous tumors that may cause severe limb deformities and early onset osteoarthritis. Total knee arthroplasty (TKA) is the method of choice for the treatment of advanced gonarthrosis, however the surgical management with coexisting severe axial limb deformity remains unclear.

CASE PRESENTATION

65-year-old man with HME and extra-articular multi-axial limb deformity was admitted to the orthopedic department due to chronic knee pain and limited range of motion caused by secondary osteoarthritis. Regarding to the clinical and radiological examinations, after preoperative planning he was qualified to a one-stage TKA combined with tibial shaft osteotomy (TSO). In a one year follow-up full bone union was confirmed with no signs of implant loosening or prosthesis displacement. Patient was very satisfied, did not report any joint pain and has sufficient range of motion without knee instability.

CONCLUSION

The improvement of mechanical axis during TKA is a crucial factor for achieve operative success and long implant survival. Despite the higher risk of complication rate in comparison to two-stage treatment, one-stage TKA with simultaneous TSO should be a considerable method for patients with osteoarthritis and multiaxial limb deformities. This method can give a good clinical and functional outcomes, however should be performed subsequently to careful preoperative planning and proper patient qualification.

The Influence of Implant Position on Final Clinical Outcome and Gait Analysis after Total Knee Arthroplasty

The aim of the study was to evaluate the impact of implant component alignment on objective and subjective outcomes after total knee arthroplasty (TKA). The rotation of the femoral component and its influence on the final results were also examined. After exclusion, the study examined 102 patients (mean age, 66.28 years; range, 51-79 years) who had undergone unilateral TKA. All of the operative procedures were performed by one surgeon with one type of implant. One year after the operation, improvements in Knee Society's Knee Scoring System, functional score, Western Ontario and McMaster Universities Osteoarthritis Index, and Visual Analog Scale were observed; however, none showed a significant correlation with any of the parameters analyzed by X-ray or computed tomography (CT) (α, β, γ, δ angles and posterior condylar angle [PCA]). Significant improvements were found for the vast majority of the parameters used for gate analysis at the final follow-up. Significant correlations were found between PCA angle and differences in stance phase, swing phase of the operated limb, and step width (all p = 0.03). No other significant relationships were found between gait parameters and indicators measured by X-ray and CT. None of the analyzed radiographic parameters, including rotation of the femoral component, correlated with final clinical results. Neither femoral internal rotation of 3° to 6°, nor rotation of 0° ± 3° or 0° ± 6° influenced the outcome. One year after TKA, a significant improvement was observed in both functional and gait parameters.

Success Rates of Revision Knee Arthroplasty for Periprosthetic Joint Infection in Rheumatoid and Non-Rheumatoid Arthritis Patients

This study evaluated the success and failure rates as well as the final results following 2-stage revision total knee arthroplasty (TKA) for periprosthetic joint infection (PJI). Particular emphasis was placed on comparing patients with rheumatoid arthritis (RA) and non-RA patients. A total of 140 knees that required 2-stage revision for PJI after TKA were analyzed. Mean patient age at first revision TKA was 67.9 years (range, 43 to 89 years), and mean time from second-stage revision to final follow-up was 53.3 months (range, 26 to 127 months). Thirty-eight of the 140 knees (27.1%) demonstrated recurrence of infection after first 2-stage revision. Of these, 8 required another 2-stage revision, 25 required knee arthrodesis, and 2 required amputation; 3 patients refused further treatment or were lost to follow-up. There was no recurrence of infection. No statistically significant differences were observed between the RA and non-RA groups in terms of success or failure rate (P=.6) according to Diaz-Ledezma and Knee Society Scores (P=.3). These findings indicate reinfection rates and final results were similar in RA and non-RA patients following revision TKA for PJI. [Orthopedics. 2019; 42(5):e472-e476.].

Intraoperative graft-related complications are a risk factor for recurrence in arthroscopic Latarjet stabilisation

PURPOSE

The goal of this study was to evaluate clinical and radiological outcomes after arthroscopic Latarjet stabilisation in anterior shoulder instability.

METHODS

Ninety-three patients after primary arthroscopic Latarjet stabilisation were reviewed. Satisfaction, subjective shoulder value (SSV), Walch-Duplay and Rowe scores, and range of motion and stability were evaluated on clinical examination. Computed tomography (CT) was used to analyse graft position and fusion.

RESULTS

Ninety patients (96.8%) were available for clinical and 85 for CT evaluation. The mean follow-up was 23.7 months (13-50, SD 7.1) and age at surgery was 26.2 years (16-44, SD 5.6). Intraoperative complications were reported in eight patients (8.9%) and recurrence in three (3.3%). Significantly, two out of three patients with recurrence had intraoperative graft complications (p = 0.0107). Forty-one patients (45.6%) reported the feeling of "subjective return to sport anxiety". External rotation with arm at the side was 59° (10-90°, SD 20) with 15° (0-70°, SD 17) of loss of rotation. These two factors correlated with results the most. Patient satisfaction was evaluated as 92% (40-100, SD 14) and SSV 90% (30-100, SD12). Revision rate after primary surgery was 10%. CT showed graft healing in 81 (95.3%) patients. A graft position between 2 and 5 o'clock was found in 70 (83.4%) patients and flush to the anterior glenoid rim in 34 (40.5%). Osteolysis of the superior part of the graft was found in 55 (64.7%) patients. CT evaluation showed no correlation with clinical results.

CONCLUSION

Arthroscopic Latarjet stabilisation demonstrates satisfactory results in short-term follow-up; however, intraoperative graft-related complications are a risk factor for recurrence. "Subjective return to sport anxiety" and loss of external rotation with the arm at the side are factors worsening the results. Graft position imperfections and osteolysis of the superior part of the graft reported in CT evaluation do not influence the clinical results.

Hip osteonecroses treated with calcium sulfate-calcium phosphate bone graft substitute have different results according to the cause of osteonecrosis: alcohol abuse or corticosteroid-induced

INTRODUCTION

The aim of the study was to assess the factors influencing the final results of treatment of the femoral head osteonecrosis (ONFH) with core decompression and bone substitute grafting. The special interest was focused on comparison between alcohol- and steroid-induced ONFHs.

MATERIAL AND METHODS

In this prospective study, a total of 53 patients (58 hips) in the mean age of 35.5 years were included: 29 had a history of alcohol use (32 hips) and 24 of steroid use (26 hips). The mean follow-up was 4.2 years (minimum 3 years).

RESULTS

At last follow-up, significant improvements were noted in the Harris Hip Score (HHS) (mean 44.0 vs 55.9 points, p < 0.00002) and VAS scores (mean 7.0 vs 5.8 points, p < 0.0002) for the whole ONFH cohort, comparing to pre-operative status. The degree of improvement did not differ between Ficat and Arlet grade II and grade III (mean 14.9 vs 6.2 points, respectively, p = 0.1). No change was found between the final and initial results in this group in the steroid group (HHS mean 42.2 vs 45.5 points, p = 0.5 and VAS mean 6.8 vs 6.5 points, p = 0.5), but the improvement was noted in the alcohol group (HHS mean 45.5 vs 64.4 points, p < 0.0001; VAS mean 7.1 vs 5.2 points, p < 0.0001) comparing to pre-operative status.

CONCLUSIONS

Presented treatment of ONFH significantly improves hip function, offers pain reduction, and gives similar functional improvement for hips scoring grade II and III on the Ficat and Arlet scale. A good response to operative treatment is seen in patients with alcohol-induced ONFH, but not in those with steroid-induced ONFH.

Two stage revision hip arthroplasty in periprosthetic joint infection. Comparison study: with or without the use of a spacer

PURPOSE

The aim of this study was to compare two methods of two-stage surgery for PJI (periprosthetic joint infection) after THA (total hip arthroplasty): one with and one without the use of an antibiotic-loaded cement spacer.

METHODS

This retrospective study was performed on 99 consecutive patients (99 hips) with a minimum follow-up of 24 months. Patients were divided into two groups: (1) in whom the operation was performed using a spacer, and (2) for whom a spacer was not used.

RESULTS

For the whole cohort, the results improved between pre-operative and final follow-up. Recurrence of infection was found in nine out of 98 patients (9.2%) and was not significantly different between the two groups. Patients treated with a spacer had better functional improvement in the interim period, but the VAS score was better in the non-spacer group. The improvement in final function was better in the spacer group with regard to HHS, but not according to WOMAC score or VAS at final follow-up.

CONCLUSION

The resection arthroplasty should be awarded particular consideration in cases of poor soft tissue quality, bone stock deficiency, when complications related to spacer use are expected or chances of new hip endoprosthesis implantation are low.

Treatment of Femoroacetabular Impingement with a Mini-open Direct Anterior Approach

BACKGROUND

The opinion about best methods of femoroacetabular impingement (FAI) treatment are not consistent. Operative treatment of this condition may be arthroscopic, but open procedures with osteotomy of the greater trochanter and hip dislocation has been used. The present study evaluates the benefits of the mini-open direct anterior approach (DAA) in treating patients with FAI, with is a procedure available for most orthopedic surgeons.

MATERIALS AND METHODS

39 patients treated for FAI (25 men and 14 women) at an average age of 29.3 years (range 18-46 years) were reviewed in this retrospective study. The mean followup was 45 months, (range 24-55 months). The hip impingement test was positive in all patients. The diagnosis of FAI was confirmed on anteroposterior and lateral hip view radiographs. All patients were operated with mini-open DAA. The outcomes were assessed with the Harris Hip Score, Short-Form 36 Health Survey and VAS score. Preoperative osteoarthritis was assessed according to Tönnis score.

RESULTS

At the final followup, improvement was noted compared to preoperative status in Harris Hip Score (P < 0.00001), visual analog scale score (P < 0.001), and Short-Form-36 score (P < 0.001). Nineteen patients returned to their previous sports activities. No major complications occurred. One patient developed heterotopic ossification and three patients developed temporary postoperative meralgia paresthetica. Five patients from the treatment group required total hip arthroplasty for severe osteoarthritis.

CONCLUSIONS

Mini-open DAA is a safe and effective procedure for the treatment of FAI that gives good relief of symptoms and allows a successful return to preoperative activity levels. Further research with a longer followup period is needed to evaluate the influence of surgery on natural history of FAI.

Short and mid term results of revision total knee arthroplasty with Global Modular Replacement System

BACKGROUND

The original knee megaprostheses with fixed or rotating hinge articulation were custom made and only used for reconstruction of the knee following distal femoral or proximal tibial tumor resections. The aim of the study was to analyze the short- and mid-term results of revision total knee arthroplasty with Global Modular Replacement System (GMRS) used in difficult situations not amenable to reconstruction with standard total knee replacement implants.

MATERIALS AND METHODS

Nine patients (9 knees) were treated with this comprehensive modular implant system, with a mean age of 73.7 years (range 56-83 years) and a mean followup of 5 years (range 3-8 years). Two patients were treated for distal femoral nonunion, five for distal femur periprosthetic fracture and two for periprosthetic joint infection.

RESULTS

The mean Knee Society Score: Knee and functional scores were 77.9 and 40 points, respectively. All demonstrated full extension and flexion was at least 90°. Recurrence of infection was present in one patient. No signs of loosening, dislocation, or implant failure were observed.

CONCLUSIONS

Based on our small series of patients that represent severe cases, GMRS provides relatively good mid-term functional results, pain relief, and good implant survivorship with a low complication rate. This salvage procedure allows elderly, infirm patients to regain early ambulatory ability.

An evaluation of the posterior cruciate ligament function in total knee arthroplasty with regard to its morphology and clinical properties

The aim of the study was to determine the degree of posterior cruciate ligament (PCL) degeneration and the reduction in the number of its mechanoreceptors, in patients with advanced degenerative joint disease. PCLs taken from study group of 50 patients in the mean age of 70.7 (53-84) years with a diagnosis of advanced idiopathic osteoarthritis undergoing condylar total knee arthroplasty were compared to those taken form the control group of 10 knee joints of cadavers. Groups were matched with regard to sex and age. Histological examination of PCLs of the study group showed changes of an inflammatory process and no significant signs of osteoarthritis in the control group. A close correlation was found between the severity of degenerative changes on the X-ray images according to the Ahlbäck scale, and the increased mucoid degeneration (p < 0.0001), the severity of the degeneration of the collagen structure (p < 0.0001) and the presence of proprioceptors of PCLs (p < 0.0001). Conserving the PCL by the use of type cruciate retaining knee arthroplasty does not guarantee the preservation of correct proprioceptive sensation.

The use of calcium carbonate beads containing gentamicin in the second stage septic revision of total knee arthroplasty reduces reinfection rate

BACKGROUND

The aim of the study was to analyze effectiveness and safety of packing the medullary canal of the tibia and femur with Herafill (Heraeus Medical GmbH, Wehrheim, Germany), a void filler and antibiotic carrier, during second stage revision total knee arthroplasty (TKA) for periprosthetic joint infection (PJI).

METHODS

Two groups were formed of 28 consecutive patients during second stage revision TKA, comparable for gender and age. The study group received Herafill, while the control group did not. The average follow-up was 52 months (minimum 36 months).

RESULTS

No reinfections were observed in the study group, while five were seen in the control group. No other differences were observed between the study and control groups, including mean clinical KSS (Knee Society score) (67.4 and 68.4 points, respectively) and functional score (72.5 and 70.5 points respectively). No side effects related to the use of Herafill beads were noted.

CONCLUSIONS

Herafill packed into the tibial and femoral intramedullary canal during second stage of septic revision TKA is a reliable bone substitute, may reduce recurrence of infection and incorporates well with host bone. However, results after PJI treatment are less than optimal measured by KSSs as compared to patients who do not require revision.

One-stage total knee arthroplasty with pre-existing fracture deformity: post-fracture total knee arthroplasty

The aim of the study was to assess the results of treating knee osteoarthrosis with total knee arthroplasty (TKA) after previous tibia and/or femur fractures resulting in axial limb deformities. Thirty-six knees (34 patients) were operated on. At the most recent follow-up, 4.8 years after surgery, all but one patient demonstrated an improvement in both clinical and functional KSS. This male patient required revision after 2 years. Improved range of motion was generally noted, especially extension, however, two patients with both tibia and femur fractures had worse results. TKA is an effective method of treatment for patients with arthrosis after a previous femur or tibia fractures. When deformity is severe semi-constrained or constrained, implants with extensions may be necessary.

Bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis: seventy eight revisions using bone allografts with or without metal reinforcements

PURPOSE

The aim of the study was to assess bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis (RA).

METHODS

We report an acetabular reconstruction using impacted, morselized, frozen, radiation sterilized bone allografts in 71 patients suffering from RA. There were sixty-six women and five men at a mean age of 57.5 years. Reconstruction was performed in 78 revision total hip arthroplasties (THAs) for aseptic loosening of acetabular component. The mean follow-up was five years and four months. In 38 cases, a revision was done with use of reinforcement devices.

RESULTS

In four revised hips (10 %) without reinforcement implants, resorption of the allografts was noticed. All Mueller rings and 50 % of unscrews cages (Link, Howmedica) were revised because of aseptic loosening and bone graft resorption. In all of 17 hips with the Burch-Schneider cage, no measurable migration or bone allografts resorption occurred. There were no major general complications.

CONCLUSIONS

Acetabular reconstruction with use of morselized, frozen, radiation sterilized bone allografts and the Burch-Schneider cage can be highly successful in managing massive deficiency of acetabular bone stock in revision hip arthroplasty in RA patients.

[Usefulness of HA+beta-TCP in bone defects repair during revision hip and knee arthroplasty]

BACKGROUND

Bone deficiency can present a surgical challenge during revision total hip and knee arthroplasty. The amount of bone grafts available for surgical purposes is insufficient. Synthetic bone substitutes can eliminate the risk of infection transmission. The purpose of the present study was to evaluate the clinical and radiographic outcomes of revision hip and knee arthroplasty with use of an impaction bone-grafting with HA+beta-TCP in reconstruction of bone defects.

MATERIALS AND METHODS

20 total hip revision (THR) and 10 total knee revision (TKR) were performed in 30 patients where impaction bone-grafting technique with HA+beta-TCP was used. Clinical, radiographic and CT results were assessed. Mean follow-up was 21 (11-48) months for THR and 22 (10-46) months.

RESULTS

Loosening was seen in 2 cups. In one case the reoperation was performed. In the second due to massive bone loss the prosthesis was removed. No another acetabular and stem components required revision surgery. There were no knee implant migration or loosening observed. The mean total HSS score was 45.3 preoperatively and 71.5 postoperatively. The mean CRS score was 35.7 preoperatively and 73.4 postoperatively.

CONCLUSIONS

The use of HA+beta-TCP with bone grafts impaction is a good method of bone defect reconstruction and can provide good short-term clinical results in revision hip and knee arthroplasty.

[Total hip arthroplasty after previous support proximal femoral osteotomy]

Clinical outcome and technical difficulties observed after total hip arthroplasty (THA) subsequent to support proximal femur osteotomy were studied in 6 total hip arthroplasties. 6 patients were follow up at an average 6.2 years after THA. The average Harris hip score before THA was 57 and after 83.6. The average leg abbreviation after THA was 1.2 cm. In one case femur perforation made impossible to stem implantation. Support proximal femoral osteotomy may make routine insertion of a femoral prosthesis difficult and jeopardize the clinical and radiological outcome of future THA.

[Scorpio TS prosthesis in severe deformity and revision knee arthroplasty--preliminary report]

Authors present early results of Scorpio TS prosthesis in primary and revision total knee arthoplasty due to aseptic and septic loosening. 26 arthroplasties were performed on 25 patients. There were 19 women and 6 men of age from 37 to 80 (average 68.4 years). 11 patients from this group were operated because of septic loosening. The follow up from 2 to 22 months (average 11 months). Early results were access according to Clinical Rating System of The Knee Society: 19 patients had very good and good (73%) including primaries, 1 satisfactory (4%) and 6 poor (23%) results. The satisfactory and poor results were obtained in 7 cases with septic loosening who had had four or more previous operations on the knee. Four of them had instability of prosthesis and we changed it for MRH type. In one case due to reinfection and sepsis amputation above the knee was performed. In another patient tibia fracture below stem and loosening of tibial component occurs after 6 months of revision. ORIF gave fracture union after 8 months and exchange Scorpio TS to MRH was performed. In two cases the wound problems occurred and was solved. There were no reinfection and aseptic loosening in another cases. We didn't notice any thrombosis complications.

[Modular short-stem prosthesis in total hip arthroplasty--preliminary report]

Total hip arthroplasty has become one of the most succesful procedure in orthopaedic surgery. More and more active, young patients undergo primary hip replacement. Bone stock preservation is crucial when performing THR in this group of patients. The short stem design allows a methaphyseal intratrochanteric multipoint, strong primary fixation which is very important for this group of patients. The goal is to save bone stock for the revision operation. This study presents early results of Metha short stems prosthesis. Between April 2006-December 2007, 58 short stem (Metha) were implanted. The Harris Hip Score improved from a mean 64.3 before to 89.7 at follow-up. The Metha stem may not be indicated for every hip diseases. There were only two fractures of femur without any further problems. Despite the short follow-up, Metha prosthesis already represent a valuable alternative for younger patients.

[Application of porous composite hydroxyapatite-TCP implants in orthopaedic surgery]

Bone grafts are the basic material in bone deficit filling. Due to difficulties to obtain bone grafts often the bone substitutes are used. Authors presents chemical, mineralogic and biologic properties of hydroxyapatite and ceramic material based on calcium phosphorate. HAp-TCP has a wide applications in bone deficit filling in knee and hip arthroplasty or revision arthroplasty, bone cysts, wrist and ankle joint arthrodesis. Bone substitutes should be mix with bone grafts, in the cases where load bearing is needed, because of their weak mechanical strength. Further clinical and experimental studies should be continued to get new generation of material on the calcium phoshorate base. This new material should present higher mechanical strength with preserving osteocondactive and osteoinductive properties of hydroxyapatite.

[Intraarticular distal radius fractures--arthroscopic assessment of injuries]

Intraarticular distal radius fractures affect predominantly young people by contrary to "loco typico" fractures concerning old patients with osteoporosis. They are usually caused by high energy trauma and their treatment needs anatomic reposition. Between August and December 2004 there were performed 10 wrist arthroscopies in distal intraarticular radius fractures: 3 women and 7 men, age from 20 to 63 years, average 41. In all cases arthroscopy revealed larger displacement than assessed by standard radiographs and multiple associated soft tissue injuries were detected: lesions of TFCC in 5 patients, cartilage lesions of carpal bones in 6 and I degree SL interosseous ligament lesion in 4 patients. Arthroscopy in distal radius fractures allows detailed articular surface displacement assessment and reposition under "eye control". Additionally associated soft tissue injuries, which are not visible in standard X-ray examination are detected and treated.

[Old and new materials in the hip prosthesis]

Since the second half of the XX century a steady evolution of hip prosthesis design is taking place. Implant shape, fixation systems and materials are constantly evolving. The paper presents the materials combinations most commonly used in hip prosthesis (metal-metal, metal-polyethylene and ceramic). All the above mentioned materials have been in used for over 25 years, and thanks to minor modification and better quality are widely used all over the world. The authors basing on biochemical studies, clinical observations and personal experience present problems related to materials used in hip prosthesis.

[Transient demineralization of the hip--case report]

Transient osteoporosis of the hip is an uncommon disorder of unclear etiology. It is often confused with other diagnosis including osteonecrosis of the femoral head. Authors describe a case of transient osteoporosis of the hip of 32 years woman. The symptoms occurred in third trimester of pregnancy. The primary symptoms were right hip pain and decreased range of motion of the right hip. In diagnostic process helpful were clinical examination, X-ray, ultrasonography, MRI and microscopic examination. As a treatment authors used walking on crutches, calcitonin and calcium preparate. After a few months remission of symptoms and normalization in accessory investigations were obtained.

[What's new in total hip replacement?]

The authors present special types of stems and acetabulum components. Analyzing the available the authors try to assess which parameters of the prosthesis influence long-term outcomes. "Wear and tear" of the implants was also analysed. Cemented and cementless acetabular components where also analysed. Capoplasties neck-sparing procedures and MIS techniques were also taken into consideration with special attention given to the dangers related to these new techniques.