Objectives. Distal humerus fractures in elderly population are often comminuted and presents multiple challenges. When managed with fixation the results are often complicated with stiffness, pain, and reduced function while total elbow replacement is fraught with lifelong restrictions on load bearing which can significantly affect elderly patients who rely assistive devices for ambulation. Elbow hemiarthroplasty however, presents a viable alternative in these cases. This series evaluates the results of the distal humerus hemiarthroplasty in a single centre. Designs and methods. Data was collected retrospectively. Comprehensive case reviews were done to collect demographic, intra-operative and post-operative data. Fractures were classified as per AO classification. The primary outcome was functional outcome and range of motion (ROM). The secondary outcomes were complications and patient satisfaction. Results. 22 cases were included in this study from 2016 – 2023 majority being females (n=18). Mean age was 74years (SD −11.2). Majority fractures were AO type C3 (n=15) with two A2 type fractures managed for non-union. Pre-existing bone on bone arthritis was present in 3 cases and CT scan was done for 12 patients to assess fracture configuration. Excluding those treated for non- union the median time between fracture and surgery was 8.5 days. Follow-up of more than 6 months was available for 16 patients with median follow-up of 18 months. ROM was available for 17 patients with 13 (50%) patients having functional ROM. No patients had full extension and there was a mean lag of 20. 0. Mean flexion was 118.2. 0. Nearly 2/3. rd. patients (73%- n=16) were satisfied with the surgery with no problems in activity of daily living. Complications seen were ulnar neuropathy (n=3), heterotopic ossification(n=2) and periprosthetic fracture (n=1). Conclusion. This single centre study suggests good outcomes following distal humerus hemiarthroplasty. It is a reasonable alternative to fixation and total elbow arthroplasty in complex fractures

Introduction & Aim. The use of All-Poly Tibia has been in practice since the early 1970's. Recently due to the reports on wear and osteolysis in other articulations, this component has generated significant interest. In the current study we aim to report early medium-term results of All-poly Tibial components in elderly (>70 years) patients. Method. Study of 455 cases done between 2005-2020. All the cases were performed by a single surgeon. All-Poly Tibial component implantations were performed using Standard mechanical jigs and the same posterior-stabilized implant was used for all cases. Results. 20 cases were lost to follow-up. 25 patients died due to natural causes. Mean age at index surgery was 74 years (70 - 91 years). Preop KSS average was 47 (31- 62). Post operative at the last follow up was 87 (71- 93). Of the 410 cases there were 8 revisions, 6 for deep sepsis and 2 for periprosthetic fractures. There were no revisions for aseptic loosening or osteolysis. All cases are performing well functionally and clinically. 18 cases had a non-progressive radiolucent line beneath the Tibial component. The combination of perfect alignment and soft tissue balance creates an environment for a successful TKR. The choice of the All-Poly Tibial component for functionally low demand age group patients reduces the chances of premature wear and osteolysis. In elderly patients the implant should outlive the patient. Here it is observed that at 5-7 years aseptic loosening and subsequent revision chances are low. The all-poly Tibial component is significantly cheaper as compared to its metal back counterpart. Conclusion. An excellent clinical result in our hands for this group of patients supports the continued use of this implant strongly

Aims

Limb salvage surgery (LSS) is the primary treatment option for primary bone malignancy. It involves the removal of bone and tissue, followed by reconstruction with endoprosthetic replacements (EPRs) to prevent amputation. Trabecular metal (TM) collars have been developed to encourage bone ingrowth (osseointegration (OI)) into EPRs. The primary aim of this study was to assess whether OI occurs when TM collars are used in EPRs for tumour.

Aims

The transepicondylar axis is a well-established reference for the determination of femoral component rotation in total knee arthroplasty (TKA). However, when severe bone loss is present in the femoral condyles, rotational alignment can be more complicated. There is a lack of validated landmarks in the supracondylar region of the distal femur. Therefore, the aim of this study was to analyze the correlation between the surgical transepicondylar axis (sTEA) and the suggested dorsal cortex line (DCL) in the coronal plane and the inter- and intraobserver reliability of its CT scan measurement.

The December 2024 Knee Roundup. 360. looks at: Unicompartmental knee arthroplasty and total knee arthroplasty in the same patient?; Lateral unicompartmental knee arthroplasty: is it a good option?; The fate of the unresurfaced patellae in contemporary total knee arthroplasty: early- to mid-term results; Tibial baseplate migration is not associated with change in PROMs and clinical scores after total knee arthroplasty; Unexpected positive intraoperative cultures in aseptic revision knee arthroplasty: what effect does this have?; Kinematic or mechanical alignment in total knee arthroplasty surgery?; Revision total knee arthroplasty achieves minimal clinically important difference faster than primary total knee arthroplasty; Outcomes after successful DAIR for periprosthetic joint infection in total knee arthroplasty

The December 2024 Research Roundup³⁶⁰ looks at: Skeletal muscle composition, power, and mitochondrial energetics in older men and women with knee osteoarthritis; Machine-learning models to predict osteonecrosis in patients with femoral neck fractures undergoing internal fixation; Aetiology of patient dissatisfaction following primary total knee arthroplasty in the era of robotic-assisted technology; Efficacy and safety of commonly used thromboprophylaxis agents following hip and knee arthroplasty; The COVID-19 effect continues; Nickel allergy in knee arthroplasty: does self-reported sensitivity affect outcomes?; Tranexamic acid use and joint infection risk in total hip and knee arthroplasty.

Aims

Approximately 10% to 20% of knee arthroplasty patients are not satisfied with the result, while a clear indication for revision surgery might not be present. Therapeutic options for these patients, who often lack adequate quadriceps strength, are limited. Therefore, the primary aim of this study was to evaluate the clinical effect of a novel rehabilitation protocol that combines low-load resistance training (LL-RT) with blood flow restriction (BFR).

Aims. Cutibacterium acnes (C. acnes; previously known as Propionibacterium acnes or P. acnes) periprosthetic hip and knee infections are under-reported. While culture contamination with C. acnes occurs, true infections are important to recognize and treat. We sought to describe the demographics and treatment outcomes of patients with C. acnes periprosthetic joint infections (PJIs) of the hip and knee. Methods. Patients with C. acnes PJI between January 2005 and December 2018 were retrospectively reviewed utilizing the institutional total joint registry. Patients with monomicrobial PJI and two or more positive cultures were considered to have true C. acnes PJI. Patients with polymicrobial infection or with only one positive culture were excluded. This resulted in 35 PJIs (21 hips and 14 knees); the patients’ mean age was 63 years (35 to 84) and 15 (43%) were female. Mean follow-up was five years (1 to 14). Results. The median time to positive culture was five days (IQR 5 to 6) and median synovial fluid cell count was 22,583 cells (IQR 15,200 to 53,231). The median ESR was 25 mm/hr (IQR 7 to 37), and CRP was 15 mg/l (IQR 3 to 29). Of the 35 PJIs, 18 (51%) were treated with chronic antibiotic suppression without surgical intervention, and the remainder were treated with two-stage exchange arthroplasty. The two-year survival free of any revision was 94%. Four patients failed treatment due to symptomatic infection, with three treated with two-stage exchange and one treated with irrigation and debridement with modular component exchange for a survival rate of 89% and 83% at two and five years, respectively. Conclusion. Laboratory evidence of C. acnes PJI in this cohort was typical compared to more conventional organisms. Cultures grew more quickly than previously thought in patients with C. acnes PJI. Treatment with two-stage exchange or chronic antibiotic suppression alone both had few treatment failures at mid-term follow-up. Cite this article: Bone Joint J 2024;106-B(12):1426–1430

Aims

Electromagnetic induction heating has demonstrated in vitro antibacterial efficacy over biofilms on metallic biomaterials, although no in vivo studies have been published. Assessment of side effects, including thermal necrosis of adjacent tissue, would determine transferability into clinical practice. Our goal was to assess bone necrosis and antibacterial efficacy of induction heating on biofilm-infected implants in an in vivo setting.

Hip fractures pose a major global health challenge, leading to high rates of morbidity and mortality, particularly among the elderly. With an ageing population, the incidence of these injuries is rising, exerting significant pressure on healthcare systems worldwide. Despite substantial research aimed at establishing best practice, several key areas remain the subject of ongoing debate. This article examines the latest evidence on the place of arthroplasty in the surgical treatment of hip fractures, with a particular focus on the choice of implant, the use of cemented versus uncemented fixation, and advances in perioperative care.

Cite this article: Bone Joint J 2024;106-B(12):1372–1376.

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes. Cite this article: Bone Joint J 2024;106-B(12):1377–1384

The December 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Predicting recurrence of instability after a primary traumatic anterior shoulder dislocation; Predictors of surgery and long-term outcomes in nonoperative management of full-thickness rotator cuff tears; Reverse shoulder arthroplasty viable despite acquired acromial compromise, but higher infection risk noted; LP-PRP reduces retear rates in rotator cuff repair but shows no functional outcome advantage; Long-term clinical outcomes of arthroscopic supraspinatus tendon repair using the single anchor tension band technique – minimum five-year follow-up; Arthroscopic stabilization for anterior shoulder dislocation shows low recurrence rates regardless of prior dislocations; ORIF outperforms arthroplasty for complex radial head fractures: mid-term outcomes; Routine use of surgical helmet systems may not reduce infection risk in shoulder arthroplasty.

Aims. For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients. Methods. The Hospital Quality Monitoring System was queried from 1 January 2013 to 31 December 2019 for displaced FNFs in geriatric patients treated with THA or HA. After propensity score matching, which identified 33,849 paired patients, outcomes were compared between THA and HA using logistic and linear regression models. Results. The HA group had a lower incidence of 90-day surgical readmission than the THA group (odds ratio (OR) 0.75 (95% CI 0.68 to 0.83)). Meanwhile, the HA group had lower incidence of dislocation (OR 0.42 (95% CI 0.33 to 0.52)), aseptic loosening (OR 0.50 (95% CI 0.38 to 0.66)), and joint pain (OR 0.63 (95% CI 0.40 to 0.98)), but a higher incidence of periprosthetic fracture (OR 1.41 (95% CI 1.07 to 1.87)) for readmission, compared to the THA group. The incidence of in-hospital complications did not differ significantly between the two groups. Moreover, the HA group had lower mean charges than the THA group (47,578.29 Chinese Yuan (CNY) (SD 20,069.71) vs 57,641.00 CNY (SD 21,524.07)). Conclusion. When considering 90-day surgical readmission rate, in-hospital complications, and mortality, HA resulted in a significantly lower surgical readmission rate within 90 days compared to THA, despite the patients being older and having a higher Charlson Comorbidity Index. Cite this article: Bone Joint J 2024;106-B(12):1477–1484

Aims

Highly cross-linked polyethylene (HXLPE) greatly reduces wear in total hip arthroplasty, compared to conventional polyethylene (CPE). Cross-linking is commonly achieved by irradiation. This study aimed to compare the degree of cross-linking and in vitro wear rates across a cohort of retrieved and unused polyethylene cups/liners from various brands.

Aim. Antimicrobial peptides occur naturally in our intrinsic immune system. PLG0206 is a novel, engineered, 24-amino acid peptide which has broad-spectrum antimicrobial activity, including in biofilm and against multi-drug resistant pathogens (1,2). This is the first clinical study to evaluate the safety and tolerability of PLG0206 when administered via an irrigation solution in patients with periprosthetic joint infections (PJI) following total knee arthroplasty (TKA) during debridement, antibiotics, and implant retention (DAIR). Secondary objectives were to evaluate pharmacokinetics (PK), biomarkers and initial clinical efficacy at one year post-DAIR procedure. Method. This prospective, multicenter, open-label, interventional study assessed two dose levels of PLG0206. Fourteen patients underwent revision for PJI after TKA. At the end of debridement, they received a single intra-articular irrigation of PLG0206 into the wound cavity lasting 15 minutes at concentrations of 3 mg/mL (n=7) or 10 mg/mL (n=7). Patients received post-operative care and intravenous/oral antimicrobial therapy as per their institutional guidelines. Patients were monitored for safety and signs of relapse or persistent infection for 12 months post study drug administration and PK and blood biomarkers were assessed. Results. All patients completed their final study assessment at Day 365. Over the 1-year follow-up, only one recurrence (7%) was noted at Day 169 in the low-dose cohort. Following dosing, nine patients (64.3%) had limited systemic exposure; maximum plasma concentration occurred 1-hour post-administration and declined rapidly to undetectable levels by 24 hours following treatment in all patients. The incidence of drug related treatment-emergent adverse events (TEAEs) was low. Two patients, both in the higher dose cohort, experienced a transient drug related TEAE; one of hypertransaminasaemia and one of neuralgia. Both events were moderate in severity and resolved within two weeks of onset. Conclusions. A single 15-minute irrigation of PLG0206 into the wound cavity of patients undergoing a DAIR procedure for PJI following TKA, is safe and well tolerated by patients. This new antimicrobial peptide offers a promising therapeutic option in musculoskeletal infection. The initial clinical efficacy is encouraging but now needs to be investigated in a much larger clinical trial

Aim. Two types of national registers surveil infections after primary total hip arthroplasty (THA) in Norway: The National surveillance system for surgical site infections (NOIS) that surveil all primary THAs 30 days postoperatively for surgical site infections (SSI), and the Norwegian Arthroplasty Register (NAR) that follow all THAs until any surgical reoperation/revision or the death of the patient. Since these registers report on the same THAs we assessed correspondence between and time trends for the two registers in period 2013 to 2022. All reported THAs were included. Method. The THAs were matched on a group level according to sex, age and ASA-class. In addition to descriptive statistics, adjusted Cox regression analyses were performed with adjustment for sex, age group (<45, 45-54, 55-64, 65-74, 75-84, >85 years) and ASA-class (1, 2, 3, 4 and missing). Changes in annual incidence and adjusted hazard rate (aHR) was calculated. Endpoints in the NOIS were 30-Days SSI and 30-Days reoperation for SSI. Endpoints in the NAR were 30-Days and 1-Year reoperation for periprosthetic joint infection (PJI). Results. The NOIS had registered 87,923 THAs with 1,393 (1.58%) SSIs and 765 (0.87%) reoperations for SSI within 30 postoperatively. The NAR had registered 91,194 THAs with 725 (0.80%) reoperations for infection after 30 days, and 1,019 (1.21%) reoperations for infections after one year. The distribution of sex, age and ASA-class was near identical in the two registers. There was a mean annual reduction in risk of both SSI (aHR 0.92 (95% CI 0.90-0.93)) and reoperation for SSI (0.95(0.92-0.97)) and PJI (30-Days: 0.96 (0.94-0.99), 1-Year: 0.95-0.99)) over the period 2013-2022. Conclusions. The NOIS and the NAR have excellent completeness and the registrations in both registers may be considered representative for the Norwegian population. Not all SSI are reoperated. The incidence and risk of SSI (NOIS) and reoperation for PJI (NAR) is declining and may reflect a true reduction in incidence of PJI after primary THA

Aim. This study aims to evaluate the effectiveness of a pre-formulated irrigation solution. 1. (containing ethanol, acetic acid, sodium acetate, benzalkonium chloride, and sterile water) compared to saline solution in managing acute periprosthetic joint infections (A-PJI) during Debridement, Antibiotic, and Implant Retention (DAIR) surgeries. The primary objective is to assess the healing rate using this solution. 1. versus saline in A-PJI patients, with “cure” defined by a set of criteria including no recurrence, wound issues, or need for ongoing suppressive antibiotics after 1 year. Principio del formularioFinal del formulario. Method. This single-center, randomized controlled trial will involve patients with acute periprosthetic infections undergoing standard DAIR surgery, divided into two groups: one receiving saline solution and the other receiving pre-formulated solution. 1. The study is single-blinded, with patients unaware of their group assignment. The study is registered at ISRCTN: https://doi.org/10.1186/ISRCTN10873696. Inclusion criteria include patients over 18 with hip or knee prostheses suffering from acute or hematogenous periprosthetic infections, while exclusion criteria include a history of prior debridement or multiple infected implants, among others. Principio del formularioFinal del formulario A total of 50 subjects are needed for statistical significance, with a 5% dropout rate anticipated. An interim safety analysis will assess early effectiveness and adverse effects, and the results are presented in this study. Data will be managed in online databases and analyzed using SPSS software, with a significance level of p<0.05. Results. Twenty-four patients were eligible for analysis, twelve in each group. The overall average age was 75 years, and the gender distribution was predominantly female (9 F and 3 M in each group). No significant differences were found at the baseline characteristics level between the two groups (p>0.05). The minimum follow-up of 1 year was achieved in all cases except three due to deaths not related to periprosthetic infection. Regarding efficacy, a non-statistically significant difference was observed (p>0.05), with 58% in the serum group and 42% in the pre-formulated irrigation solution. 1. group (X. 2. = 0.17, p=0.683). The average hospital stay was 38.42 days (SD 26.32) in the pre-formulated irrigation solution group. 1. and 24.42 days (SD 18.72) in the serum group, with this difference being not significant (t=1.5, p=0.148). Conclusions. While the current analysis indicates no significant differences between both groups in terms of efficacy, the study's ongoing progress and the inclusion of a larger sample size could potentially yield more definitive results

Aim

An instrumented blood culture system automatically flags when growth within the culture medium has been detected (‘work in progress’), and subsequently when the organism has been identified.

We explore using this data to switch patients to oral therapy within 72 hours post-surgery, reducing costs and improving antimicrobial stewardship.

Aim. Evaluate the metabolites composition of the synovial fluid from patients with PJI or aseptic failure of total knee arthroplasties. Method. The synovial fluids from 21 patients scheduled for revision total knee arthroplasty (11 with the diagnosis of PJI and 10 with aseptic failures) were analyzed using 1D 1H NMR spectroscopy. Univariate and multivariate statistical analyses were used to identify metabolites that were differentially abundant between those groups. Results. A total of 28 metabolites were identified and five of them found to be differentially abundant between infected and non-infected synovial fluids. Lactate, acetate and 3-hydroxybutyrate were found to be in a higher concentration, and glucose and creatine were found reduced in the synovial fluid from PJI patients. Conclusions. Synovial fluid from patients with PJI exhibit a distinct metabolic profile, possibly reflecting metabolic adaptation that occurs in the infected periprosthetic microenvironment. Further research and studies are warranted to gain a broader insight into the metabolic pathways engaged by both pathogen and immune cells in the context of a PJI