Open debridement, irrigation with implant retention and antibiotic treatment (DAIR) is an accepted approach for early prosthetic joint infections (PJI). Our aim was to design a score to predict patients with a higher risk of failure.

From 1999 to 2014 early (<90 days) PJIs without signs of loosening of the prosthesis were treated with DAIR and were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need of an unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement.

A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Fifty-two (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR:5.92, 95%CI:1.47–23.85), liver cirrhosis (OR:4.46, 95%CI:1.15–17.24), revision surgery (OR:4.34, 95%CI:1.34–14.04) or femoral neck fracture (OR:4.39, 95%CI:1.16–16.62) compared to primary arthroplasty, CRP >11.5 mg/dL (OR:12.308, 95%CI:4.56–33.19), cemented prosthesis (OR:8.71, 95%CI:1.95–38.97) and when all intraoperative cultures were positive (OR:6.30, 95%CI:1.84–21.53). Furthermore, CRP showed a direct relationship with the percentage of positive cultures (Linear equation, R2=0,046, P=0.002) and an inverse association with the time between the debridement and failure (Logarithmic equation, R2=0.179, P=0.003). A score for predicting the risk of failure was done using pre-operative factors (KLIC-score, figure 1) and it ranged between 0–9.5 points. Patients with a score ≤2, >2–3.5, 4–5, >5–6.5 and ≥7 had a failure rate of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively.

The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.

Early prosthetic joint infections (PJI) are managed with debridement, implant retention and antibiotics (DAIR). Our aim was to evaluate risk factors for failure after stopping antibiotic treatment.

From 1999 to 2013 early PJIs managed with DAIR were prospectively collected and retrospectively reviewed. The main variables potentially associated with outcome were gathered and the minimum follow-up was 2 years. Primary endpoint was implant removal or the need of reintroducing antibiotic treatment due to failure.

A total of 143 patients met the inclusion criteria. The failure rate after a median (IQR) duration of oral antibiotic treatment of 69 (45–95) days was 11.8%. In 92 cases PJI was due to gram-positive (GP) microorganisms, in 21 due to gram-negatives (GN) and 30 had a polymicrobial infection. In GP infections, combination of rifampin with linezolid, cotrimoxazole or clindamycin was associated with a higher failure rate (27.8%, P=0.026) in comparison to patients receiving a combination of rifampin with levofloxacin, ciprofloxacin or amoxicillin (8.3%) or monotherapy with linezolid or cotrimoxazole (0%) (Figure 1). Among patients with a GN infection, the use of fluoroquinolones was associated with a lower failure rate (7.1% vs 37.5%, P=0.044). Duration of antibiotic treatment was not associated with failure.

The only factor associated with failure was the oral antibiotic selection, but not the duration of treatment. Linezolid, cotrimoxazole and clindamycin but not levofloxacin serum concentrations are reduced by rifampin; a fact that could explain our findings. Further studies monitoring serum concentration could help to improve the efficacy of these antibiotics when combining with rifampin.

Introduction: Although the influence of preoperative nutritional status on short term outcome in arthroplasty is well known, its relationship with early prosthetic joint infection (EPJI) in total knee replacement remains unclear.

Aim: Our aim was to assess the effect of preoperative nutritional status on patients who went on to present with EPJI following total knee replacement surgery. This assessment was based on preoperative blood tests and anthropometric measurements.

Methods: A total of 213 patients undergoing total knee replacement between December 2007 and May 2008 were included in the study. Patients with rheumatoid arthritis were excluded. For each patient we pre-operatively checked haemoglobin level, CRP, ESR, total lymphocyte and protein count, albumin and pre-albumin concentration and triglicerids, cholesterol and creatinine levels. Triceps skindfold and arm/muscle circumference were measured the day before surgery. The body mass index was calculated based on the information contained in the anaesthetic chart. We also collected information about co-morbidities such as Diabetes, High blood pressure, ASA grading, age and gender. Information about early infections, both superficial and deep, was collected. A descriptive statistical analysis and logistic regression models approach for independent risk factors were performed.

Results: The mean age was 71.5 years. There were 162 female and 51 male. Eleven patients (5.16%) had early wound infection: 5 deep EPJI and 6 superficial. Neither co-morbidities nor preoperatively laboratory test except CRP (OR 1.44, p=0.03) were associated with a high early infection risk. However, there was an inversely proportional relationship between EPJI and anthropometric measurements: triceps skindfold (OR 0.9 p=0.011) and fat area (FA) (OR 0.94, p=0.01).

Conclusion: A low triceps skindfold and FA were associated with an increment of risk of EPJI after a knee replacement. Although the relationship between some laboratory test as pre-albumin and lymphocyte account and wound healing and postoperatively complications is well known, we didn’t find it with EPJI in our group except for CRP levels.

In primary total knee arthroplasty (TKA) performed under ischemia the antibiotic prophylaxis is administered 15’ before inflating the tourniquet. The infection rate in TKA is higher than in hip arthroplasty. We hypothesise that ischemia could impair the efficacy of the antibiotic. The objective of our study was to compare the effectiveness of two schedules of antibiotic administration.

We conducted a randomised and a double blind study. Patients were assigned to receive placebo 15’ before inflating tourniquet and cefuroxim 1.5 g 10’ before releasing the tourniquet (experimental arm) or cefuroxim 1.5 g 15’ before inflating tourniquet and placebo 15’ before releasing tourniquet (standard arm). In both arms cefuroxime 1.5 g was administered 6 hours after finishing surgery. The variables gathered were: age, sex, indication for TKA, co-morbidity, ASA score, duration of the operation, number of blood transfusions, days of hospitalisation and number of surgical site infections after 3 months of surgery. Categorical variables were compared using the χ² test or the Fisher exact test and quantitative variables using Student-t test.

Nine hundred and eight patients were randomised and 466 and 442 patients were allocated to experimental and standard arms respectively. Both groups were similar and there were no differences in deep and superficial infection rates, 1.39% and 4.18% for experimental arm and 3.39% and 3.17% for standard arm (p> 0.05). The experimental arm had a lower global and deep infection rate than the standard arm when the length of surgery was lower than the 75th percentile (global: 4.03 vs 7.93%, p=0.04, deep: 1.72% vs 4.44%, p=0.07).

The administration of antibiotic prophylaxis 10’ before releasing the tourniquet decreases the surgical site infection rate when the duration of surgery is lower than the 75th percentile.

Introduction and purpose: Our aim was to determine a morphometric relation between the long head of the brachial biceps and the bicipital groove with respect to the subscapular tendon, and its repercussion on functional imbalance of the shoulder.

Materials and methods: For this analytical observational crossover study we took a sample of 30 right-handed, sedentary, duly informed male subjects. The morphometric study was carried out with ultrasonography using a cross-section of the long head of the brachial biceps.

Results: In the dominant limb: 1. Bicipital groove (depth 2.6 mm, width 13.4 mm, internal angle 149.8°); 2. Long head of the brachial biceps (area 1.35 mm, internal angle 152.53°, echogenicity 97.95); 3. Subscapular thickness 4.53 mm. In the non-dominant limb: 1. Bicipital groove (depth 2.9 mm, width 12.5 mm, internal angle 145.73°); 2. Long head of the brachial biceps (area 1.07 mm, internal angle 141.32°, echogenicity 112.72); 3. Subscapular thickness 4.12 mm.

Conclusions: The greater the thickness of the subscapular tendon: 1. Bicipital groove (greater width and internal angle, less echogenicity and depth); 2. Long head of the brachial biceps (greater area and internal angle, less echogenicity). Therefore, there is a greater risk of dislocation of the long head of the brachial biceps and functional instability of the shoulder.

Introduction and purpose: This study analyzes the clinical and radiographic results of two generations of the same uncemented acetabular component.

Materials and methods: The analysis comprised 83 Harris-Galante I (HGI) shells (with a 32 mm femoral head) and 93 Harris-Galante II shells (HGII) (with a 28 mm femoral head. Mean follow-up was 12.5 + 2.52 years for the HGI shells and 7.8 + years for the HGII ones. PE wear was assessed by means of image digitalization and computer software (AutoCAD).

Results: There were two cases of loosening amongst the HGI shells (Kaplan-Meier 96.9%) and one among the HGII ones (98.3%) (p = 0.7107). 4 PE replacements had to be performed due to wear in the HGI (90.7%). There were three dislocations of the PE insert in the HGI shells ( 79.7%) and one in the HGII ones (97.9%) (p = 0.883). Acetabular osteolysis was observed in 7 cases, out of which 5 were HGI and 2 HGII,. The osteolysis was related to a higher initial settling on the PE (position zero) ( p = 0.0062), a higher mean wear rate (p = 0.001), and a higher wear rate at the end of follow-up (p = 0.002). Position zero was 0.15 + 0.04 mm for HGI shells and 0.11 + 0.02 for HGII ones (p < 0.001). The mean wear rate was 0.13 + 0.23 mm/year and 0.11 + 0.09 respectively (p = 0.740). PE insert dislocation appeared after an average of 117 + 60.3 months, with a position zero of 0.15 mm for dislocated shells and y 0.13 mm for non-dislocated ones. The respective mean wear rates were 0.94 mm and 0.10 mm (p = 0.001).

Conclusions: Stable radiographical fixation was observed in the majority of shells of both generations. Osteolysis was related with higher wear. The second generation shows a lower position zero which leads to less wear at the end of follow-up, but not to a lower mean wear rate.

Introduction and purpose: This study analyses the long-term results and the polyethylene wear rate of a first-generation hemispherical porous shell.

Materials and methods: 40 Tri-Lock shells were analyzed associated to an ACS (DePuy) PE insert implanted between 1988 and 1992. The PE had been gamma sterilized in air. The mean follow-up until revision or last control was 9.3 years (range: 3.1–15.0). PE wear was assessed by means of image digitalization with an Auto-CAD 14R software after 6 weeks (position zero), 6 and 12 months and, then, once a year. All cases were associated to a Profile stem.

Results: All shells showed themselves to be radiographically osseointegrated. 7 cases had acetabular osteolysis (Kaplan-Meier survival: 74.1% at 13 years). The appearance of osteolysis was related to a higher average wear rate (p=0.0021) and a higher wear rate at the end of follow-up (p=0.0147). 11 cases showed a breakage of the PE (Kaplan-Meier survival: 61.69+29.9% at 13 years). These breakages appeared on average after 60.1 months. The distance between the axis of the femoral head and that of the shell on the initial radiograph (position zero or initial settling) was 0.6018 in cases with breakage and 0.2338 in cases with no breakage (p=0.009). PE breakage was related to a higher mean wear rate (p< 0.0001) and the verticalization of the shell (p=0.0016).

Conclusions: Although all Tri-Lock cups were osseoin-tegrated, the breakage of the ACS insert was an usual finding, which was related with a higher initial settling of the PE, a higher mean wear rate and the verticalization of the shell.

Introduction and Objectives: Acute ruptures of the Achilles tendon are often treated surgically. The minimally-invasive technique of end-to-end suture has gained popularity in recent years. However, the use of reinforcing tendinous plasties can yield a more solid reconstruction, permit an earlier rehabilitation programme, and reduce the risk of re-rupture. The goal of this study is to determine the long-term results and complications of repairs using reinforcing plasties in the treatment of acute ruptures of the Achilles tendon.

Materials and Methods: Between 1995 and 2001, a total of 56 consecutive Achilles tendon ruptures were repaired using end-to-end suture and primary tendinous reinforcement. Average patient age was 35 years (range: 23–75), and 87% were males. Average time of postoperative immobilization was 4 weeks, and average time to discharge was 6 weeks. Average follow-up time was 4.7 years (range: 2–8 years).

Results: At the end of the follow-up period, 51 patients (89%) showed normal ankle function and had returned to their normal pre-injury activities. There were no complete re-ruptures. One patient presented with a partial traumatic re-rupture of the central area of the tendon, which did not require surgical treatment. There were 2 cases of deep infection, 10 patients with surgical wound problems, and 2 patients with transient paresthesia in the sural nerve area.

Discussion and Conclusions: Reconstruction of acute ruptures of the Achilles tendon using tendinous plasty for reinforcement gives satisfactory results in a high percentage of patients, permitting earlier rehabilitation with very low risk of subsequent re-rupture. However, the procedure is associated with a high rate of cutaneous complications and infection.