Management of septic arthritis and prosthetic joint infection

Management of joint infection is an evolving topic. This article reviews the literature on the management of native and prosthetic joint infection and suggests some areas of improvement in short- and long-term management which could lead to better patient outcomes. Surgical management is the mainstay of treatment for native or prosthetic knee infection and aspiration should only be used for diagnostic purposes. A multidisciplinary team approach and compliance with national guidelines, alongside referral networks and pooling of expertise, should be mandatory to improve patient outcomes.

A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee

BACKGROUND

There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee.

PURPOSE

To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis.

RESULTS

Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02).

CONCLUSION

Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI.

REGISTRATION

International Standard Randomised Controlled Trial Number: 48911177.

Anterior cruciate ligament rupture and management

Anterior cruciate ligament rupture is a common knee injury in young people. It is the commonest cause of an acute haemarthrosis following trauma. Acute management involves aspiration, the restoration of full movement, followed by muscle rehabilitation. The long-term natural history of non-operative management is usually a failure to return to high level sports and in most, symptomatic instability with secondary meniscal and chondral injury. The late outcome is that of premature degenerative arthritis. Reconstructive techniques are now advanced and minimally invasive. However, considerable technical skill and experience is required to avoid complications. Physiotherapy guided rehabilitation over 4-6 months is vital prior to a return to sport. The stabilised knee should reduce secondary injury and progressive degenerative disease. In the future an increased number of reconstructions, tissue engineered grafts and accelerated healing will probably be seen.

Successful two-stage revision of a KineSpring® joint unloading implant: a case study

Few nonsurgical treatment options are available to the patient with debilitating knee osteoarthritis (OA) that is refractory to conservative care. The KineSpring® System joint unloading implant is a unique device that reduces the load carried by the medial compartment of the knee joint by up to 13 kilograms during the stance phase of gait. We report a case of a male patient who underwent implant with the KineSpring System for symptomatic knee OA but subsequently required revision due to local infection. We performed a novel two-stage revision procedure where the absorber unit was removed in the first phase and a new absorber was placed 3 months later after the infection resolved. A key finding of this case was that knee OA pain resolved with the KineSpring System, returned following explant of the absorber unit, and resolved again following implant of the new absorber. Another important aspect of this case was that the femoral and tibial bases of the KineSpring System remained in situ, which simplified each phase of the revision procedure.

The use of intradiscal steroid therapy for lumbar spinal discogenic pain: a randomized controlled trial

STUDY DESIGN

A prospective randomized study of the therapeutic effect of intradiscal steroid injection compared to a saline placebo.

OBJECTIVES

To determine whether intradiscal steroid injection influences the clinical outcome at 1 year in patients with chronic low back pain of discogenic origin.

SUMMARY OF BACKGROUND DATA

Steroids have been used empirically in the treatment of back pain. They have been used in the epidural space and around nerve roots and have been used as an alternative to chymopapain within the disc. Previous studies have, however, shown variable results.

METHODS

A total of 120 patients with chronic low back pain of discogenic origin were enrolled in the study. At discography, if they had concordant pain, they were randomized to injection of normal saline or methylprednisolone into the disc space. These patients were prospectively followed up for 12 months, and they were asked to report pain according to a visual analogue score and their Oswestry Disability Index was recorded. The primary outcome measure was determined as a percentage change in disability, and the results were analyzed using independent samples t test. The secondary outcome measure was a change in the pain score, and this was analyzed using the Mann-Whitney U test.

RESULTS

There was no significant difference in the primary outcome between the two groups (P = 0.71). The steroid group had a mean change of 2.28 (SE 2.49) in percentage disability, while the saline group had a mean change of 3.42 (SE 1.79). With respect to the change in pain score, there was no significant difference between the two groups (P = 0.72). Those patients who had saline injection had a median change in pain score of 0 (interquartile range -1 to 1), whereas those given steroid treatment had a median change in pain score of 0 (interquartile range -0.25 to 1).

CONCLUSIONS

This study demonstrates that intradiscal steroid injections do not improve the clinical outcome in patients with discogenic back pain compared with placebo.

Bone mineral density after removal of rigid plates from forearm fractures: preliminary report

Bone mineral density (BMD) was measured on three occasions following removal of metal plates used to fixate diaphyseal forearm fractures in eight patients (mean age 38.5 years). At plate removal the mean BMD of the distal radius/ulna and the ulnar shaft sites were, respectively, 10.2% and 2.1% lower than on the nonfractured side. The apparent volumetric BMD (BMDvol) at the ulnar fracture site was 4.3% lower. At 6 months follow-up ( n = 5) the mean ulnar shaft BMD had increased by 6.4% ( P = 0.04), resulting in complete recovery of BMD, whereas the increase in BMDvol did not reach the BMDvol of the control side. No recovery was found at the distal radius/ulna site. We conclude that there is a small, partially reversible bone density deficit in the ulnar shaft that has been underneath the plate. Although the decreased bone density may in part be responsible for increased refracture risk at the fracture site immediately after plate removal, it is negligible after 6 months. The cessation of the effects of stress shielding is probably responsible for the increased bone density after plate removal.

Bone mineral density after the removal of intramedullary nails: a cross-sectional and longitudinal study

We measured bone mineral density (BMD) using dual X-ray absorptiometry (DXA) at several sites in both fractured and nonfractured limbs in eight patients with femoral shaft fracture and six with tibial shaft fracture at the time of the intramedullary (IM) nail removal. Seven patients were followed up for an average of 13 months. The BMD at the proximal part of the femur and tibia was from 3% to 11% lower in the fractured side as compared to the nonfractured side. The greatest bone loss (13%-21%) was found in the operated distal tibia of the patients with tibial shaft fractures. At the fracture site of the femur, BMD was 10.5% ( P < 0.05) higher, possibly owing to fracture callus formation, whereas tibial shaft BMD was not increased. However, a calculated apparent volumetric BMDvol at the fracture site was 15%-16% decreased. Although BMDs of the fractured side almost reached the baseline level of the nonfractured side (96.9%-102.1%) by the final follow-up (>12 months), the absolute deficit was still 3%-9%. Surprisingly, significant BMD increases (5%-6%) were also detected in all proximal femoral measurement sites of the contralateral limb, which indirectly suggests that the uninjured limb may also suffer from bone loss after lower-extremity trauma. We conclude that clinically important bone loss exists in the proximal femur and proximal and distal tibia of the fractured limb at the time of IM nail removal. Although areal BMD was higher at the femoral fracture site, the lower apparent volumetric BMDvol suggests decreased mineralization and reduced strength of the fracture site. Although the present results do not suggest special recommendations for restricted weight bearing after the removal of IM nails, the relationship between decreased bone density and increased risk of fractures should be borne in mind.

Is titanium so bad?

Early failures have seen titanium fall from favour as a material for cemented femoral stems. Between 1989 and 1994, we performed a prospective review of a consecutive series of 122 cemented total hip replacements using the Ultima straight textured titanium stem, and report the five- to ten-year clinical and radiological outcomes. There were no revisions for loosening of the femoral stem. Revision surgery was undertaken for other reasons such as dislocation, infection and loosening of the cup in 7.3%. Of those patients without revision all but two were satisfied with their hip, with 74% graded good or excellent using a modified Harris hip score. Radiological assessment revealed probable loosening in two. Although slight vertical subsidence was found in one-third of patients it had not progressed to loosening. It is not clear whether this represents debonding. Non-progressive radiolucent lines (1 to 2 mm) were present in zone 1 at the cement-prosthesis interface in 14.7%. Calcar resorption and hypertrophy around the distal stem were not often seen. With 97% survival at a mean of 7.5 years, the medium-term results of this specific cemented titanium stem are reassuring so far, but we are concerned about debonding and future failure.

Is titanium so bad? Medium-term outcome of cemented titanium stems

Early failures have seen titanium fall from favour as a material for cemented femoral stems. Between 1989 and 1994, we performed a prospective review of a consecutive series of 122 cemented total hip replacements using the Ultima straight textured titanium stem, and report the five- to ten-year clinical and radiological outcomes. There were no revisions for loosening of the femoral stem. Revision surgery was undertaken for other reasons such as dislocation, infection and loosening of the cup in 7.3%. Of those patients without revision all but two were satisfied with their hip, with 74% graded good or excellent using a modified Harris hip score. Radiological assessment revealed probable loosening in two. Although slight vertical subsidence was found in one-third of patients it had not progressed to loosening. It is not clear whether this represents debonding. Non-progressive radiolucent lines (1 to 2 mm) were present in zone 1 at the cement-prosthesis interface in 14.7%. Calcar resorption and hypertrophy around the distal stem were not often seen. With 97% survival at a mean of 7.5 years, the medium-term results of this specific cemented titanium stem are reassuring so far, but we are concerned about debonding and future failure.

The thin tube pedicle: a valuable technique in auricular reconstruction after trauma

We describe a three staged method of reconstruction for partial helical rim defects using a thin post auricular tube pedicle. The technique is illustrated by three case reports.