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.

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.

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.

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.

[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.