Aim. White blood cell (WBC) scintigraphy for diagnosing fracture-related infections (FRIs) has only been investigated in small patient series. Aims of this study were (1) to establish the accuracy of WBC scintigraphy for diagnosing FRIs, and (2) to investigate whether the duration of the time interval between surgery and WBC scintigraphy influences its accuracy. Method. 192 consecutive WBC scintigraphies with . 99m. Tc-HMPAO-labelled autologous leucocytes performed for suspected peripheral FRI were included. The goldstandard was based on the outcome of microbiological investigation in case of surgery, or - when these were not available - on clinical follow-up of at least six months. The discriminative ability of the imaging modalities was quantified by several measures of diagnostic accuracy. A multivariable logistic regression analysis was performed to identify predictive variables of a false-positive or false-negative WBC scintigraphy test result. Results. WBC scintigraphy had a sensitivity of 0.79, a specificity of 0.97, a positive predicting value of 0.91, a negative predicting value of 0.93 and a diagnostic accuracy of 0.92 for detecting an FRI in the peripheral skeleton. The duration of the interval between surgery and the WBC scintigraphy did not influence its diagnostic accuracy; neither did concomitant use of antibiotics or NSAIDs. There were 11 patients with a false-negative (FN) WBC scintigraphy, the majority of these patients (n = 9, 82%) suffered from an infected nonunion. Four patients had a false-positive (FP) WBC scintigraphy. Conclusions. WBC scintigraphy showed a high diagnostic accuracy (0.92) for detecting FRIs in the peripheral skeleton. Duration of the time interval between surgery for the initial injury and the WBC did not influence the results which indicate that WBC scintigraphy is accurate shortly after surgery

Tc 99m labelled leukocytes scintigraphy (LLS) could be useful for the diagnosis of bone and joint infections. The aim of our study was to evaluate its performances specifically in the diagnosis of prosthetic joint infection (PJI). We conducted a multicenter -7 year- retrospective study including 164 patients with suspected PJI who underwent surgical treatment. In each case, 5 intraoperative samples were taken. Diagnosis of infection was confirmed if two or more samples yielded the same microbial agent. LLS was considered as « positive » if an accumulation of leukocytes was observed in early stage and increased in late stage (24 hours). Among these patients, 123 had also a bone scintigraphy. A total of 168 PJ were analyzed: 150 by in vitro polymorphonuclear labelled leukocytes scintigraphy (PLLS) and 18 by anti-granulocytes antibodies labelled leukocytes scintigraphy (LeukoScan®). Location of PJ were: hip (n = 63), knee (n = 71), miscellaneous (n = 4). According to microbiological criteria 62 hip prosthesis and 48 knee prosthesis were considered as infected. Sensitivity (Se), Specificity (Sp), Positive Predictive Value (PPV) and Negative Predictive Value of PLLS were: 72%, 60%, 80% and 47%. Se of LLS was higher for knee PJI (87%) than for hip PJI (57%) [p = 0.002]. Although Sp was higher for hip PJI (75%) than for knee PJI (52%) [p = 0.002]. The lowest Se was found for coagulase negative staphylococci (70%) and the highest for streptococci (87.5%). However the difference of Se between bacteria was not significant. Regarding bone scintigraphy, Se, Sp, PPV and NPV were: 94%, 11%, 65% and 50%. In our study, performances of LLS were rather low and varied according to the location of infection. Differences of LLS Se between bacteria was not significant. Bone scintigraphy has a high Se but lacks Sp

Purpose: The diagnosis of chronic bone and joint infections, particularly in patients with implants, can be a difficult task. Among the clinical and laboratory tests proposed for the diagnosis of infection, 99mTc HMPOA labelled leukocyte scintigraphy is one of the least invasive examinations available. We evaluated its efficacy in terms of reliability. Material and methods: Ninety patients with suspected bone and joint infections were included in this study: 53% men and 47% women. Mean age was 56.6 years and 80% had osteosynthesis implants. Mean duration of clinical signs before scintigraphy was 6.5 months. The suspected site was the hip in 49%, the knee in 28% and another in 23%. Physical examination (local aspect, temperature) and laboratory tests (differential count, platelets, CRP, ESR) as well as standard radiographs were performed in addition to labelled scintigraphy. These patients were operated and bone samples were taken for bacteriology studies to confirm or infirm the presence of infection. In this series, 73% of the patients were found to have a real infection (73% staphylococcal, 17% multiple germs, 20% other). Results: The following variables were included in the multivariate analysis: fever, standard radiographs, polynuclear neutrophil count, CRP, ESR, leukocyte-labelled scintigraphy. Sensitivity (Se), specificity (Sp), and odds ratio (OR) were determined. The multivariate analysis showed: fever (Se=0.48; Sp=0.59; OR=1.3); abnormal radiograph (Se=0.71; Sp=0.62; OR=4; p=0.02); polynuclear neutrophil count (OR=1; p=0.19); CRP (OR=1.02; p=0.06); ESR (OR=1.03; p=0.04); leukocyte-labelled scintigraphy (Se=0.71; Sp=0.82; OR=11.6; p< 0.001). Discussion and conclusion: These findings demonstrate the efficacy of 99mTc HMPOA-labelled leukocyte scintigraphy in terms of reliability for the diagnosis of chronic bone infection compared with other clinical (fever), laboratory (ESR, CRP), and radiographic indicators

Purpose of the study: Chronic foot compartment syndrome is a rather new notion illustrated by four cases reported in the international literature. We report a new case with bilateral involvement. The diagnosis was established by dynamic thallium scintigraphy and suggested that a less invasive management would be appropriate. Case report: A 32-year-old male Foreign Legion recruit developed exercise-induced pain in the medial portion of the plantar aspect of both feet. The pain persisted for several months and resisted medical treatment. No medical or surgical event could be identified in the patient’s history. Pain developed systematically with exercise which had to be interrupted. It regressed progressively after interruption of exercise. The physical examination and podoscopy were not contributive. Laboratory tests, plain x-rays, MRI, and bone scintigraphy were normal. The diagnosis of chronic foot compartment syndrome was entertained. Dynamic thallium-201 scintigraphy was performed on both feet to compare the soft tissue images. Intense uptake was observed on the early images and late images of the plantar vault. These images, present on both feet, were considered compatible with chronic foot compartment syndrome. Positive diagnosis was confirmed with pressure measurements in the medial compartment. Fasciotomy was performed for the medial compartment. The patient was able to run normally at one month with complete regression of the symptoms. The patient was symptom free at two years. Discussion: Compartment pressure measurements currently constitute the gold standard diagnostic approach. MRI, Doppler, spectroscopy, and scintigraphy have been proposed. For this functional disorder, which occurs only after exercise, we consider that compartment pressure measurement is overly invasive and painful. Furthermore, dynamic thallium-201 scintigraphy has been found to be as reliable as pressure measurements. Comparative studies would be required to determine the best evidence-based choice. Conclusion: Chronic foot compartment syndrome is a rare entity observed in the active young subject. The medial compartment is always involved. Fasciotomy is effective treatment. Compartment pressure measurements remain the gold standard but dynamic scintigraphy would be a promising examination which merits evaluation

Introduction: Labelled leukocyte scintigraphy has been shown to be a sensitive and specific technique for the detection of pedal osteomyelitis in patients with diabetes mellitus. There has however been little data relating the efficacy of the technique to outcomes. Aim: To examine the prognostic value of sequential 99m Tc labelled leukocyte scans at diagnosis and after 3–4 weeks of appropriate antibiotic therapy. Method: Twenty-three patients with proven pedal osteomyelitis or persistent uptake on the sequence of scans were studied. Results: Five additional episodes of osteomyelitis developed in the group over the period of the study. Eleven patients demonstrated persistent uptake in the sequential scans. Nine progressed to amputation. The remaining two patients were biopsy negative for infection, did not have cutaneous ulceration and were thought to have rapidly progressive arthropathy. Conclusion: Sequential leukocyte scintigraphy accurately predicted the need for amputation and circumvented ineffective prolonged antibiotic therapy

Infection after total joint arthroplasty can present a diagnostic challenge. No preoperative tests are consistently 100% sensitive and specific, so the diagnosis of infection depends on the surgeon’s judgment with respect to the clinical presentation and examination and interpretation of the results of investigations. The consequences of misdiagnosis are severe. Reimplantation of a prosthesis into an infected host bed is likely to result in persistent infection. Preoperative investigations include haematological screening tests (white blood cell count, ESR, and C-reactive protein), joint aspiration and arthrography, radiography, and radionuclide imaging studies. Intraoperative investigations include analysis of synovial fluid, gram-staining of tissue that appears inflamed, histological evaluation of frozen sections of inflamed tissue, and culture of periprosthetic tissue. The exclusion of infection as a cause of failure is imperative to determine the management of patients who need revision total joint replacement. The key to making the correct diagnosis is using not a single investigation but rather a correct combination of investigations. From 2001 to 2004 we studied 46 patients referred from various centres with prosthesis loosening. The patients had technetium and gallium scintigraphy. In 32 patients, scintigraphic studies suggested septic loosening. Of these, 21 patients also had aspirations, three intraoperative cultures and 11 both aspirations and intraoperative cultures. The remaining 11 patients had aseptic loosening and were used as a control group. In only 10 patients was sepsis proved by aspiration or culture. Our results, which show that scintigraphy has a dismal positive predictive value as a screening test and a good negative predictive value, concur with the current literature

We report the largest multicentre series analysing the use of bone scans investigating painful post-operative Total Knee Replacements (TKR). We questioned the usefulness of reported scintigraphic abnormalities, and how often this changed subsequent management. 127 three-phase bone-scans were performed during a two-year period. Early and late flow phases were objectively classified. Reported incidences of infection and loosening were determined. Reports were subjectively summarised and objectively analysed to establish the usefulness of this investigation. Eight cases were excluded.

Scans were classified as: 33% (39) normal, 53% (63) as possibly abnormal, 6% (7) probably abnormal, and 8% (10) as definitely abnormal. Thirteen patients (11%) underwent revision TKR surgery. Intra-operative analysis revealed loosening of one femoral component, and massive metallosis of the patella in another. Cultures were negative in all cases. The sensitivity and specificity of a definitely abnormal investigation in predicting need for revision surgery was 23% and 82% (respectively). High instances of ambiguously reported abnormalities were observed.

This investigation has no role to play in the routine investigation of a painful TKR. It is unnecessary in investigation of periprosthetic infection and should not be used in a routine assessment of a painful TKR. If used it should be limited until an experienced revision surgeon has made a full assessment.

Objectives

To study the vascularity and bone metabolism of the femoral head/neck following hip resurfacing arthroplasty, and to use these results to compare the posterior and the trochanteric-flip approaches.

After knee replacement, therapy resistant, chronic synovitis is common and leads to effusion and pain. A cohort of 55 patients with 57 knee replacements and chronic synovitis underwent radiosynoviorthesis. In summary, 101 joints were treated using 182±9 MBq of 90Y-citrate. The number of radiosynoviorthesis ranged from 1 to 4 (53%, 21%, 23%, and 4%). Every patient received a 99mTc-MDP scintigraphy before and three months after every radiosynoviorthesis. Follow-up ranged from 5.7 to 86.7 months. For qualitative analysis, an four steps scoring was used (0 = no response or worsening, 1 = slight, 2 = good, 3 = excellent response). For quantification, the uptake was determined within the 99mTc-MDP scintigraphy soft tissue phase before and after therapy. At the end of long-term follow-up 27% of patients have an excellent, 24% good, 30% slight and 20% no response. The duration of response was 7.5±8.3 months (maximum 27 months). In repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, three months after the last radiosynoviorthesis, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated radiosynoviorthesis had a higher effectiveness at similar duration response. In the 99mTc-MDP scan 65% of patients showed a reduction of uptake. When comparing subjective and objective response 78% of patients showed a concordance in both, symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles. Radiosynoviorthesis is effective in patients with knee replacement and chronic synovitis. It shows good subjective and objective response rates and long response duration. Repeated treatment leads to a stronger long-time response. The chronic synovitis is caused by plastic particles, which result from the abrasion of the polymeric inlay of endoprothesis

Aim. Diagnosing Fracture-Related Infections (FRI) is challenging. White blood cell (WBC) scintigraphy is considered the best nuclear imaging technique to diagnose FRI; a recent study by our group found a diagnostic accuracy of 92%. However, many centers use . 18. F-fluorodeoxyglucose positron emission tomography/computed tomography (. 18. F-FDG-PET/CT) which has several logistic advantages. Whether . 18. F-FDG-PET/CT has better diagnostic performance than white blood cell (WBC) scintigraphy is uncertain. Therefore, we aimed: 1) to determine the diagnostic performance of . 18. F-FDG-PET/CT for diagnosing FRI (defined as infection following an open fracture or fracture surgery) and 2) to determine cut-off values of standardized uptake values (SUV) that result in optimal diagnostic performance. Method. This retrospective cohort study included all consecutive patients who received . 18. F-FDG-PET/CT to diagnose FRI in two level 1 trauma centers. Baseline demographic- and surgical characteristics were retrospectively reviewed. The reference standard consisted of at least 2 representative microbiological culture results or the presence or absence of clinical confirmatory FRI signs in at least 6 months of clinical follow-up. A nuclear medicine specialist, blinded to the reference standard, re-reviewed all scans. Additionally, SUVs were measured using the “European Association of Nuclear Medicine Research Ltd. (EARL)” reconstructed . 18. F-FDG-PET/CT scans. Volume of interests were drawn around the suspected- and corresponding contralateral area to obtain the absolute values (SUVmax) and the ratio between suspected and contralateral area (SUVratio). Diagnostic accuracy of the re-reviewed scans was calculated (sensitivity and specificity). Additionally, diagnostic characteristics of the SUV measurements were plotted in the area under the receiver operating characteristics curve (AUROC). The sensitivity and specificity at the optimal threshold was deducted from the AUROC with the Q-point method. Results. 158 . 18. F-FDG-PET/CTs were included. Mean age was 46.2 years, 71.5% was male. Most cases (56.3%) were tibial shaft- or ankle fractures. Sixty patients (38.0%) had FRI. The sensitivity and specificity of the FDG-PET/CT scan was 70.0% (95% CI 56.8–81.2) and 79.6% (95% CI 70.3–87.1) respectively. Diagnostic accuracy was 76.0% (95% CI 68.5–82.4). AUROCs of SUVmax and SUVratio were 0.80 (95% CI 0.73–0.87) and 0.73 (95% CI 0.64–0.81), respectively. The optimal SUVmax threshold of 4.2 resulted in 80.0% sensitivity and 71.3% specificity, while an SUVratio of 2.9 resulted in 58.3% sensitivity and 80.9% specificity. Conclusions. The . 18. F-FDG-PET/CT has a sensitivity of 70.0%, specificity of 79.6% and a diagnostic accuracy of 76.0%. This makes . 18. F-FDG-PET/CT less accurate than WBC scintigraphy in diagnosing FRI, although adding SUV measurements may possibly increase its diagnostic accuracy

Introduction: Occult fractures of carpal bones are underestimed. To be treated succesfully fractures of the scaphoid must be identified at an early stage. A delay in detection may result in non union. We validated with 3 prospective studies a new tool using scintigraphy : The quantitative Xray bone scan (QRS). Material and Methods: A previous preliminary prospective study with 60 patients was performed and published to valid the QRS as a step in diagnosis of wrist occult bones fractures equal to RMI. This exam is a bone scan with 2 improvments. 1) A quantification of the fixation spot : If the spot is two times more important on the injuried wrist (than controlateral side) the fracture is sure. 2) If you combine plain Xrays of the the wrist with scintigraphy the fracture is automatically located. This previous report pointed that repeat set of scaphoid views, dynamic and static, Ct scan, proved unsuitable for screening occult fractures of the wrist. Result: Between november 97 and march 04, 667 patients were enrolled in a prospective continue study. 40% (260/667) of patients with an injury of the wrist with normal X ray sustained an occult fracture. QRS was performed at an average of 17,7 days after the injury and after clinical exam and repeat set of scaphoid view. Scaphoid fractures were most frequent. Fixation was most important if scintigraphy was performed between 11 and 20 days after the injury. Fixation did not depend on age, sex, volume of the bone, and delay (after 15 days). Discussion: As Dikson, Dias, Thompson, and Kuckla, repeat set of scaphoid view are unable to improve significativally the number of occult fractures of the wrist. RMI as reported by Kuckla can reduce the need for further imaging procedure. RMI and scintigraphy are both the best exam to diagnose surely an occult fracture of the wrist. But QRS does not over diagnose, as RMI, bones fracture’s. Conclusion: “Plaster cast and wait” is not the treatment for occult carpal bones fracture’s. The quantitative Xray bone scan is able to diagnose such fractures with short delay

Background and objectives. Positron emission tomography (PET) is a technology widely used in oncology. It is now being increasingly used in orthopaedics, especially in diagnosing bone infection. Diagnosis of bone infection is still a challenge, especially after surgery. Bone scintigraphy, Gallium-67 scintigraphy, and radiolabelled leucocyte scintigraphy are not specific. MRI has problems with definition in the presence of metal. PET uses 18-F Fluoro deoxyglucose(FDG) as a radiotracer. Inflammatory cells use glucose for energy, and the 18F-Fluoride component of FDG is a positron-emitting radionucleotide. We undertook this study to show our experience with the FDG-PET –CT in diagnosing bone infection and to highlight its superiority in diagnosing infected spine implants. Material and Methods. Medical records of orthopaedic patients referred to the nuclear medicine department in our hospital were retrospective reviewed. We looked at the clinical records, radiographs, bone scintigraphs, MRI and FDG-PET, assessing their diagnostic accuracy, and their value in helping the surgeon plan treatment. Results. There were 37 patients referred for possible diagnosis of bone infection. 14 had proven spine infection on FDG-PET scan. 5 of these had infected spine implants. The FDG-PET scan showed better definition of the anatomical site of the infection, allowing the surgeon to plan surgery better. Also it was not affected by presence of implants. Conclusion. FDG-PET-CT is the modality of choice for diagnosing bone infection. It is particularly useful in defining the anatomical site of the infection, especially in irregular bones, like the vertebrae. NO DISCLOSURES

Aims: The diagnosis of a prosthetic joint infection is difþcult, but crucial for appropriate treatment. Scintigraphy with speciþc markers for infection (labeled white cells or immunoglobulin-G) has been reported as a more reliable diagnostic tool than clinical assessment (fever, þstula), laboratory studies [polynuclear neutrophils blood count (PNC), erythrocyte rate sedimentation (ESR), and C-reactive protein (CRP)], and preoperative aspiration. Methods: In the þrst part of this study, we retrospectively reviewed 230 patients admitted with a suspected prosthetic joint infection and compared the validity of these different diagnostic tools. 209 patients had an infection. Results: Pain, fever, ESR, and PNC are unreliable for identifying occult infection. The presence of a þstula is inconstant, but when present is very reliable to detect infection. Our study revealed sensitivity, speciþcity, positive and negative predictive value as follows: CRP: 97%, 81%, 98%, 71% respectively; aspiration: 82%, 94%, 99%, 43% respectively, and labelled scintigraphy 74%, 76%, 91%, 44% respectively. In the second part, we reviewed 23 articles which included 1,722 prosthetic joints with preoperative evaluation of infection. Conclusions: Both our study and the literature review indicate that CRP and joint aspiration are the best tools to diagnose prosthetic joint infection

Antigranulocyte scintigraphy with the use of monoclonal antibodies or antibody fragments (leukoscan) is a promising diagnostic tool that has been used widely during the recent years for the establishment of prosthesis infection after total hip or knee arthroplasty. In the present study we report the Ioannina University Hospital experience in the diagnostic efficacy of leukoscan for the diagnosis of prosthesis infection in patients with total hip or knee arthroplasty. We considered all patients with suspected total hip or knee arthroplasty infection that had undergone a leukoscan examination for the diagnosis of this infection in our department during the year 2004. All patients underwent a 3-phase bone scan and a subsequent leukoscan. For the whole group of patients the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated by comparison of the results of three-phase bone scan or leukoscan with the results obtained from cultures of synovial fluid obtained from articular puncture or cultures of intraoperative sampling from those patients that had undergone a revision surgery. A total of 19 patients with total joint arthroplasty (12 THA and 7 TKA) and suspected prosthesis infection were included in the study. The mean age of patients was 67 years. Twelve patients had verification of prosthesis infection in cultures. The overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for the three-phase bone scan were 54%, 83%, 88%, 45% and 63% respectively. On the contrary, the overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for leukoscan were 75%, 86%, 90%, 66% and 79%, respectively. Antigranulocyte scintigraphy with the use of monoclonal antibody fragment sulesomab (leukoscan) had good but not perfect diagnostic performance for the diagnosis of prosthesis infection in patients with total hip or knee arthroplasty

Athletes are prone to iterated traumatic straining of sacroiliac joints and insertion of muscles in pelvic bones. The aim of our study was to show the connection between iterated trauma and staphylococcal infection in athletes. A compilation of data concerning 22 patients, all high-ranking athletes in Sweden, with pelvic skeletal infection (symphysitis, sacroiliitis and acetabular necrosis) is presented. Most of them were ball-players, 2 females and 20 males with an average age of 21 years. The onset was acute or subacute and the disease was commonly misinterpreted, mainly as an acute abdominal disease. Four patients erroneously underwent laparotomy for suspected appendicitis. Eight patients had skin lesions (5 purulent and 3 uninfected) at the onset and thus had a portal for possible entry for a bacterial impact in the pelvic skeleton. The only verified bacterial aetiology was Staphylococcus aureus in 19 cases (culture of blood and/or aspirated samples in 18 and serology only in 1). An early scintigraphy was of greater value than X-ray for diagnosis and was positive in 8/10 evaluable cases. In all, 12/18 had early positive plain radiological findings. Another patient (#22) had, except skeletal infection, a psoas abscess, diagnosed by Magnetic Resonance Imaging (MRI). Antistaphylococcal drugs administered parenterally for 1–2 weeks followed by oral drugs for a few months comprised a successful treatment and no patient had serious sequelae or relapse. The occurrence of abdominal and/or lower back pains concomitant to fever in young persons engaged in elite team sports should lead to a suspicion of pelvic pyogenic infection. Early scintigraphy and cultures of blood and aspirated material from the infection site was essential for the diagnosis. MRI has also been shown to be valuable

Introduction: In temperate places pyomyositis is very uncommon in children and adolescents. West European and North American Literature about is relatively poor (104 articles from 1998 to nowadays and most of these papers are case-rep orts). S. Aureus is the etiologic agent in 90% of cases. Muscle of the thighs and hips are the most frequent localisation and severe complications are observed in 10% of cases. Material and Methods: We reviewed all patients affected by primary pyomyositis and admitted in our Department from 1995 to nowadays. Age, sex, history and clinical findings, general and local risk factors were reported. X-rays, Ultrasonography, MRI, Scintigraphy, Haematological investigation and culture were considered in order to state the imaging and laboratory findings of the disease. Result: Pyomyositis was diagnosed in three males, aged 11, 13 and 16. There was no evidence of medical or familiar risk factors. Soleus, Otturatorius and Psoas muscles were respectively involved. In all cases fever, local signs of inflammation and pain, neutrophylic leukocytosis, increased ESR and CRP levels were present. Blood culture was positive in one case. Standard X-Rays were normal in all cases. Ultrasound scan, RMI and Scintigraphy were positive but non-specific in all cases. 2 cases underwent to surgical drainage and a 3 weeks antibiotic therapy; 1 case resolved performing only medical treatment (5 weeks of antibiotic). All patients showed complete clinical, haematological, and RMI recovered without reliquates. Conclusions: Pyomyositis is uncommon in temperate climate and it may be easy misdiagnosed at the onset. In our patients the mean time from onset of symptoms to diagnosis was 10 days. History and clinical examination might be evocative, but there are no pathognomonic haematological or radiological findings so that diagnosis is often the result of extensive and wide considerations. Pyomyositis should be suspected in any unclear septic condition of the musculoskeletal apparatus. High index of suspicion, prompt diagnosis, and early treatment can prevent complications and allow the recovery of this potentially life-threatening disease

Aims

This study evaluated the definitions developed by the European Bone and Joint Infection Society (EBJIS) 2021, the International Consensus Meeting (ICM) 2018, and the Infectious Diseases Society of America (IDSA) 2013, for the diagnosis of periprosthetic joint infection (PJI).

Introduction: Stress fractures comprise a major problem in female police or army recruits. The incidence of stress fractures is reported ranging from 3 to 10 fold when compared to male recruits taking the same training program. This study consisted of an intervention program aiming at reducing combat gear weight and locating the gear as close as possible to the body center of gravity. Material and Methods: In a prospective study we followed up two companies of female recruits of the Israel Border Police. Both companies were followed for the four months of basic training using a basic data questionnaire inclusive of previous physical activity habits, previous acute and overuse injuries, menstrual history and previous smoking habits. An injury questionnaire was filled on commencement of the course and every two weeks thereafter. The clinical records of medic and doctor visits, as well as the personal medical file, were revised. Roentgenological and scintigraphic imaging were performed during the course, when clinical suspicion of a stress fracture arose. The first company of 71 fighters used the standard combat gear amounting to 12.5 kg. The second company of 64 fighters used combat equipment weighing 9.4 kg, held in a combat girdle close to the body center of gravity, inclusive of a shorter personal combat riffle and personal combat vest. Results: There was no difference in the number of clinic visits between the two companies. Complaints suggesting stress fractures were recorded in the first company from the 3. rd. to the 8. th. week of training and in the second from the 1. st. to 3. rd. week. The percentage of fighters sent for Scintigraphy because of clinical suspicion of stress fractures was 22.5% in the first company and 6.25% in the second. The percentage of fighters in whom stress fractures were located by Scintigraphy was 15.5% in the first company and 4.7% in the second. The number of stress fractures in average per fighter was 0.45 fractures in the first company and 0.27 fractures in the second. When calculating only “dangerous” stress fractures (long bones and navicular) there were noted 0.34 fractures per fighter in the first company and 0.20 in the second. Total average training days lost for reason of stress fractures was 2.21 per fighter in the first company and 1.08 in the second. Conclusions: Reducing the weight of the fighting gear and securing it closer to the body center of gravity may have a positive effect in reducing the incidence of stress fractures in female recruits of fighting units during the intense basic training program

Despite of improved operative technique, ultra-clean air in the operating theater and systemically administered as well as in bone cement loaded antibiotics, septic complications after replacement arthroplasty of the knee still exist. Depending of the follow-up time in different reported series insidence vary from 0.5 to 5 per cent. Classic clinical symptoms, painful, swollen knee joint, possibly fever, indicate to more accurate examinations. Lesson to learn: . No treatment before adequate diagnosis !. No “homeostatic” antibiotics before accurate examinations. If the very first contact with physician or surgeon happens in such conditions, that adequate diagnostic methods are not available, patient has to be referred to hospital or institution with capable facilities. Prosthetic infection can be classified in many ways. The following classification is useful for the treatment purposes. Classification of infection:. 1. Early postoperative infection less than 4 weeks after surgery. superficial. deep. extensive soft tissue defects due to skin necrosis. 2. Originally patient is operated for aseptic loosening, but intraoperative cultures are positive. 3. Late chronic infection. 4. Acute hematogenous infection. Diagnostic methods:. 1. Clinical examination:. - symptoms can be suppressed by painkillers or immunomodulant drugs. - wound healing problems. - sinuses. - swelling, redness. - pain. - temperature increased. 2. Blood chemistry:. ESR, C-reactive protein and blood white cell count/ differentiation are helpful. Be ware if the patient has such a general disease, which increases fex CRP. 3. Routine x-rays. In early cases no significant signs, in late cases might appear erosions or cysts. 4. Isotope scintigraphy. Technetium- or indium labeled leucosytes are given intravenously. The patient is scanned 24 hours. Extended scintigraphy seems to be more sensitive than routine 6 to 8 hours‘ scintigraphy. 5. Joint aspiration. One has to sure, that the patient is not on antibiotics. If she/he is, antibiotics has to be stopped for two to four weeks, and aspiration performed after that, unless infection is not clinically obvious or situation is not life-threatening. White cell count/differentiation can be for some help. When the cell count is less than 2000/ml, and majority of cells are mononuclear, the result is indicative negative for infection. White cell count over 10000/ml, and majority polymorphonuclear, speaks for infection. When the aspiration has been carried in aseptic condition, positive culture is strong evidence for infection. Adequate handling of sample is important: as little as possible air in the syringe and as short as possible time used for transportation to lab. Treatment protocols. Treatment protocols can rather straight forward: if any sample culture is positive,. Two-stage revision arthroplasty is carried out. But also more conservative opinions are reported. 1.a. Early postoperative, superficial infection:. Surgical débridement of the wound. Careful examination of retinaculum layer. Lavage and wound closure if possible. Systemic antibiotics. Joint puncture and aspiration through healthy skin area, never through open wound. b. Early postoperative, deep infection:. Open débridement and careful lavage with retention of prosthesis. Additional peroperative samples for culture in order to confirm earlier pathogene definition. Systemic antibiotics regarding sensitivity estimation. Arthroscopic debridement and lavage has not proved to be better or neither as good as open. New aspiration 4–6 days after. If white cell count clearly over 10000/ml and possibly culture positive, new debridement and lavage. If third debridement comes necessary, even without bony changes, removal of prosthesis and antibiotics- loaded spacer has to be considered. c. Dehiscense of wound or soft tissue defect due to the necrosis:. Wound débridenent, antibiotics and depending on the extend of defect either partial closure, skin grafting or pedicled gastrocnemius muscle flap is performed. 2. In some cases there is no signs of infection, and the is operated as an aseptic loosening. In all revision, routineously 4 to 5 tissue samples should be taken for culture. If preoperatively there is any doubts about infection, histological examination of frozen sections should be carried out. If there are high count of polymorphonuclear cells, results of culture has to be waited. If later on in minimum two samples same pathogen is growing, the case has to be considered as infected. Two-stage revision protocol is recommended. One positive sample cannot be regarded as a concluding proof. Long term antibiotics is recommended. 3. Late chronic infection has insidious , slowly progressing onset. Symptoms can be confusing mild, and can lead to misdiagnosis. Method of choice is débridement, removal of the prosthesis and all bone cement, and placement of an antibiotics-loaded cement spacer. No dead space is left , but has to be filled with antibiotic-loaded collagen or antibiotic-cement beads. The patient is put on systemic antibiotics, preferably combination of two. Antibiotic therapy is continued six- to eight weeks. Healing process is controlled with ESR and CRP tests. If the blood test normal and clinical situation is normal, delayed revision arthroplasty is performed. Antibiotic loaded-cement is always used. 4. Acute hematogenous infection. Onset is usually acute and symptoms dramatic. Sometimes distant focus can be found. If the history is rather short( less than 14 days) open débridement, retainment of prosthesis, antibiotics-loaded collagen filling of the joint as well systemic antibiotics is recommended. Recovering is monitored by blood chemistry and repeated joint aspiration and cultures. If in aspiration sample there is high polymorphonueclear count and culture possibly positive, new débridemand is carried out. If signs of infection still continue, two-stage exchange to be considered. Pathogenes. Gram-positive. staphylococci are most frequent patogene in total knee replacement infections (95%). Gram-negative. bacilli cover the rest (5%). Coagulase-negative staphylococci has grown up the most important bacteria, and it‘s resistance against antibiotics has turned frightening. Spacers. In cases with short history retainment of prosthesis can be considered. Many authors change of polyethylene bearing. In two-stage revisions static antibiotic-loaded cement spacer was used during. The six to eight weeks‘ interval. Static spacer is connected with extensive bone loss as well as stiff causing problems in secondary revision. Molded cement spacer is used in order to avoid complications and to achieve better functional results. Failure. In some cases treatment of infection is unsuccessful. Arthodesis with method of Ilizarov or intramedullary nail or sometimes above-knee amputation comes necessary

Aims

Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications.