Aims. Arthroplasty has been shown to generate the most waste among all orthopaedic subspecialties, and it is estimated that hip and knee arthroplasty generate in excess of three million kg of waste annually in the UK. Infectious waste generates up to ten times more CO2 compared with recycled waste, and previous studies have shown that over 90% of waste in the infectious stream is misallocated. We assessed the effect of real-time waste segregation by an unscrubbed team member on waste generation in knee and hip arthroplasty cases, and compared this with a simple educational intervention during the ‘team brief’ at the start of the operating list across two sites. Methods. Waste was categorized into five categories: infectious, general, recycling, sharps, and linens. Each category was weighed at the end of each case using a digital weighing scale. At Site A (a tertiary orthopaedic hospital), pre-intervention data were collected for 16 total knee arthroplasy (TKA) and 15 total hip arthroplasty (THA) cases. Subsequently, for ten TKA and ten THA cases, an unscrubbed team member actively segregated waste in real-time into the correct streams. At Site B (a district general hospital), both pre- and post-intervention groups included ten TKA and ten THA cases. The intervention included reminding staff during the ‘team brief’ to segregate waste correctly. Results. Active real-time waste segregation reduced infectious waste by a mean of 2.51 kg (95% CI 1.492 to 3.542) in TKA, and 1.83 kg in THA cases (p = 0.004). Educational intervention reduced infectious waste by a mean of 3.52 kg in TKA and 2.09 kg in THA cases (p = 0.026). Total waste was significantly reduced in both groups post-intervention for TKA cases. Conclusion. Simple educational measures alone can significantly reduce the amount of infectious waste. Extrapolated nationally, our results would yield a reduction of approximately 315,004 kg to 594,577 kg of CO2 annually, which equates to 70 to 132 gasoline-powered passenger vehicles driven for a year. Cite this article: Bone Jt Open 2024;5(12):1119–1124

Objectives. Acetabular fractures with quadrilateral plate involvement have been shown to have a high rate of complications. Anatomic suprapectineal plating systems have been developed to manage these injuries with good short-term outcomes, however long-term maintenance of anatomical reduction and functional outcomes is yet to be established. Efficacy of maintenance of reduction and functional outcomes at a minimum of 5-years follow-up is the aim of this study. Design and Methods. A retrospective cohort study examining patients aged over 16 years following fixation of acetabular fractures with quadrilateral plate involvement at a trauma centre in the United Kingdom. All patients had acetabular fracture fixation with an anatomically designed suprapectineal plate. Patients were admitted from March 2014 to January 2017. Primary outcomes included objective radiological outcomes such as reduction quality, maintenance of reduction, metalwork failure, complications (such as reoperation, neurological deficit and mortality) and subjective patient-related outcome measures (PROMs) using the Oxford Hip Score and EuroQol EQ5D Score at a minimum of 5-years post-operatively. Results. 16 patients met our eligibility criteria in this cohort. Post-operative mean Oxford Hip Score (OHS) at a minimum of 5-years was 40.5 (SD 11.9) with a median score of 45. Post-operative mean EuroQol EQ-5D scores at a minimum of 5-years were 0.83 (SD 0.25). Comparison of OHS and EQ5D at 1-year and 5-years showed no significant difference (OHS p = 0.27 / EQ5D p = 0.128). Radiographic outcomes were assessed with AP and Judet plain radiographs at a minimum of 5-years follow-up. Rate of conversion to total hip replacement was 6.25%. 56.3% showed some evidence of dome comminution with 18.8% demonstrating dome impaction. 93.7% showed evidence of quadrilateral plate involvement. 12.5% showed evidence of femoral head injury. Conclusion. Maintenance of reduction and functional and patient reported outcomes using anatomically contoured suprapectineal plates do not change significantly between 1 year and 5 years follow-up

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This meta-analysis and systematic review aimed to comprehensively investigate the effects of vitamin K supplementation on bone mineral density (BMD) at various sites and bone metabolism in middle-aged and older adults.

Aims. Better prediction of outcome after total hip arthroplasty (THA) is warranted. Systemic inflammation and central neuroinflammation are possibly involved in progression of osteoarthritis and pain. We explored whether inflammatory biomarkers in blood and cerebrospinal fluid (CSF) were associated with clinical outcome, and baseline pain or disability, 12 months after THA. Methods. A total of 50 patients from the Danish Pain Research Biobank (DANPAIN-Biobank) between January and June 2018 were included. Postoperative outcome was assessed as change in Oxford Hip Score (OHS) from baseline to 12 months after THA, pain was assessed on a numerical rating scale, and disability using the Pain Disability Index. Multiple regression models for each clinical outcome were included for biomarkers in blood and CSF, respectively, including age, sex, BMI, and Kellgren-Lawrence score. Results. Change in OHS was associated with blood concentrations of tumour necrosis factor (TNF), interleukin-8 (IL-8), interleukin-6 receptor (IL-6R), glycoprotein 130 (gp130), and IL-1β (R. 2. = 0.28, p = 0.006), but not with CSF biomarkers. Baseline pain was associated with blood concentrations of lymphotoxin alpha (LTα), TNFR1, TNFR2, and IL-6R (R. 2. = 0.37, p < 0.001) and CSF concentrations of TNFR1, TNFR2, IL-6, IL-6R, and IL-1Ra (R. 2. = 0.40, p = 0.001). Baseline disability was associated with blood concentrations of TNF, LTα, IL-8, IL-6, and IL-1α (R. 2. = 0.53, p < 0.001) and CSF concentrations of gp130, TNF, and IL-1β (R. 2. = 0.26, p = 0.002). Thus, preoperative systemic low-grade inflammation predicted 12-month postoperative outcome after THA, and was associated with preoperative pain and disability. Conclusion. This study highlights the importance of systemic inflammation in osteoarthritis, and presents a possible path for better patient selection for THA in the future. Preoperative central neuroinflammation was associated with preoperative pain and disability, but not change in OHS after THA. Cite this article: Bone Joint Res 2024;13(12):741–749

The December 2024 Arthroplasty Roundup³⁶⁰ looks at: Aspirin for hip and knee arthroplasty?; VTE prophylaxis; VTE prophylaxis part II.

Aims

This study aimed to determine clinical outcomes; relationships between postoperative anterior, lateral, and posterior acetabular coverage and joint survival; and prognostic factors for joint survival after transposition osteotomy of the acetabulum (TOA).

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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.

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.

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.

Aims. Day-case knee and hip replacement, in which patients are discharged on the day of surgery, has been gaining popularity during the last two decades, and particularly since the COVID-19 pandemic. This systematic review presents the evidence comparing day-case to inpatient-stay surgery. Methods. A systematic literature search was performed of MEDLINE, Embase, and grey literature databases to include all studies which compare day-case with inpatient knee and hip replacement. Meta-analyses were performed where appropriate using a random effects model. The protocol was registered prospectively (PROSPERO CRD42023392811). Results. A total of 38 studies were included, with a total of 83,888 day-case procedures. The studies were predominantly from the USA and Canada, observational, and with a high risk of bias. Day-case patients were a mean of 2.08 years younger (95% CI 1.05 to 3.12), were more likely to be male (odds ratio (OR) 1.3 (95% CI 1.19 to 1.41)), and had a lower mean BMI and American Society of Anesthesiologists grades compared with inpatients. Overall, day-case surgery was associated with significantly lower odds of readmission (OR 0.83 (95% CI 0.73 to 0.96); p = 0.009), subsequent emergency department attendance (OR 0.62 (95% CI 0.48 to 0.79); p < 0.001), and complications (OR 0.7 (95% CI 0.55 to 0.89) p = 0.004), than inpatient surgery. There were no significant differences in the rates of reoperation or mortality. The overall rate of successful same-day discharge for day-case surgery was 85% (95% CI 81 to 88). Patient-reported outcome measures and cost-effectiveness were either equal or favoured day-case. Conclusion. Within the limitations of the literature, in particular the substantial risk of selection bias, the outcomes following day-case knee and hip replacement appear not to be inferior to those following an inpatient stay. The evidence is more robust for unicompartmental knee replacement (UKR) than for total knee replacement (TKR) or total hip replacement (THR). The rate of successful same-day discharge is highest in UKR, followed by TKR and comparatively lower in THR. Cite this article: Bone Joint J 2024;106-B(12):1385–1392

The December 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Establishing best practice for managing idiopathic toe walking in children: a UK consensus; Long-term outcomes of below-elbow casting in paediatric diaphyseal forearm fractures; Residual dysplasia risk persists in developmental dysplasia of the hip patients after Pavlik harness treatment; 3D printing in paediatricorthopaedics: enhancing surgical efficiency and patient outcomes; Pavlik harness treatment for hip dysplasia does not delay motor skill development in children; High prevalence of hip dysplasia found in adolescents with idiopathic scoliosis on routine spine radiographs; Minifragment plates as effective growth modulation for ulnar deformities of the distal radius in children; Long-term success of Chiari pelvic osteotomy in preserving hip function: 30-year follow-up study.

The December 2024 Hip & Pelvis Roundup. 360. looks at: Total hip arthroplasty after femoral neck fractures versus osteoarthritis at one-year follow-up: a comparative, retrospective study; Excellent mid-term survival of a monoblock conical prosthesis in treating atypical and complex femoral anatomy with total hip arthroplasty; Hip arthroscopy for femoroacetabular impingement improves sexual function; Fast-track hip arthroplasty does not increase complication rates; Ten-year experience with same-day discharge outpatient total hip arthroplasty: patient demographics changed, but safe outcomes were maintained

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. Methods. Polyethylene acetabular cups/liners were collected at one centre from 1 April 2021 to 30 April 2022. The trans-vinylene index (TVI) and oxidation index (OI) were determined by Fourier-transform infrared spectrometry. Wear was measured using a pin-on-disk test. Results. A total of 47 specimens from ten brands were included. The TVI was independent of time in vivo. A linear correlation (R. 2. = 0.995) was observed between the old and current TVI standards, except for vitamin E-containing polyethylene. The absorbed irradiation dose calculated from the TVI corresponded to product specifications for all but two products. For one electron beam-irradiated HXLPE, a mean dose of 241% (SD 18%) of specifications was determined. For another, gamma-irradiated HXLPE, a mean 41% (SD 13%) of specifications was determined. Lower wear was observed for higher TVI. Conclusion. The TVI is a reliable measure of the absorbed irradiation dose and does not alter over time in vivo. The products of various brands differ by manufacturing details and consequently cross-linking characteristics. Absorption and penetration of electron radiation and gamma radiation differ, potentially leading to higher degrees of cross-linking for electron radiation. There is a non-linear, inverse correlation between TVI and in vitro wear. The wear resistance of the HXLPE with low TVI was reduced and more comparable to CPE. Cite this article: Bone Joint Res 2024;13(11):682–693

Aim. Periprosthetic joint infection (PJI) is one of the main reasons for revision surgery after primary unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) or total hip arthroplasty (THA). Currently the MSIS and EBJIS criteria sets are considered to be the gold standards in determining PJI. These criteria sets are complex and contain tests that are time-consuming and many are rather costly. Therefore, further research is indicated to find a simpler but equally reliable diagnostic test. In this study we evaluated the additional value of calprotectine measurement in synovial fluid in patients undergoing hip and knee (revision) arthroplasty following routine work-up. Method. In a retrospective cohort study, we analyzed 182 synovial fluid samples from 143 patients with suspected PJI after UKA, TKA, THA or revision arthroplasty. Twenty-six of those cases were classified as PJI according to the MSIS and EBJIS criteria. Subsequently, synovial calprotectin was determined, using a lateral flow assay and two cut-off thresholds of ≥14 mg/L and ≥50 mg/L. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of synovial calprotectin was determined. Results. When applying the MSIS and EBJIS criteria and a calprotectin level ≥14 mg/L, synovial calprotectin revealed an area under the curve of 0.96 (95% CI 0.90-1.00), with 92.3% sensitivity and 100% specificity. The PPV and NPV were 100% and 92.9% respectively. When applying the MSIS and EBJIS criteria and a calprotectin level ≥ 50 mg/L, synovial calprotectin revealed an area under the curve of 0.94 (95% CI 0.87-1.00), with 88.5% sensitivity and 100% specificity. The PPV and NPV were 100% and 89.7% respectively. Conclusions. The value of calprotectin in synovial fluid gives valuable information with a single test result, resulting in high predictive value in the diagnosis of PJI after hip or knee arthroplasty and should seriously be considered as part of PJI diagnostics in an outpatient clinical setting. The high specificity can help rule in patients that are suspected of PJI. Therefor this test can be helpful in a preop diagnostic work-up to avoid unnecessary revisions in patients with well-placed and well-fixed arthroplasties with a suspected PJI. These conclusions are independent of which criteria set was used as a gold standard

Aim. Periprosthetic joint infection (PJI) and periprosthetic fracture (PF) are one of the most devastating complications in arthroplasty. Each complication by itself is challenging to solve. Yet, simultaneously, both complications are inconceivably complex to deal with, while the treatment regimen of PJI and PF are contradictory. Chronic PJI most often requires implant removal, while PF requires stability, regularly achieved by stable osteosynthesis. This study aims to (1) analyse the success rate of PJI with following concomitant PF during the treatment course in total hip arthroplasties (THA) and (2) to determine the risk factors for reinfection and subsequent revision surgery after treatment of PJI and PF. Method. This restrospective study analyzed 41 patients with concomitant PJI and PF during the PJI treatment period from 2013 to 2022 involving THA. Patients were divided in two cohorts termed success and failure and were statistically compared. The median follow-up time was 66 months (>12 months). All patients were considered individually and treated according to their individual needs in fracture and infection treatment. Re-arthroplasty survival was analyzed using the Kaplan-Meier method. Relevant risk factors were analyzed using the Mann-Whitney test or Chi-square, depending on the variable's scale. Results. The overall success rate of our cohort was 70,7%. Twelve patients required re-operation due to reinfection, resulting in a cumulative 12-month-reinfection rate of 19,5%. The estimated cumulative reinfection free survival rate was 68,3%. Significance in risk factors for failure were found in pathogen virulence grade, Difficult to treat pathogen and number of debridement during interval. On average the Harris Hip score was 66 in the group of reinfection compared to 77 in the group of success. Conclusions. Reoperation and re-infection rate remains high in patients with simultaneous PJI and PF in THA. Due to the heterogeneity of the fractures, soft tissue conditions and pathogens found, treatment must be individualised to salvage the limb. However, small cohorts impact the statistical strength negatively due to instances of two rare complications

Aim. Periprosthetic joint infection (PJI) is a devasting complication after total hip arthroplasty. Joint aspiration and preoperative biopsy can be helpful diagnostics for PJI. The aim of this study is to evaluate the diagnostic value of preoperative biopsies after inconclusive or dry tap aspiration of the hip in patients undergoing revision hip arthroplasty. Secondarily we will evaluate the diagnostic value of synovial fluid aspiration cultures and peroperative tissue cultures for diagnosing or ruling out PJI. Methods. Patients who underwent diagnostic aspiration and subsequent preoperative biopsy and/or revision surgery between January 2015 and January 2024 were included in the study. Synovial fluid aspirations and tissue samples obtained from biopsy and revision surgery were interpreted using the European Bone and Joint Infection Society criteria for PJI and in close consultation with the microbiologist. Results. 207 Patients were included with 231 synovial fluid aspirations. Sensitivity and specificity of synovial fluid aspiration cultures were 76% and 98%. In 62 patients tissue biopsies were performed, of which 40 after a dry tap. The tissue biopsies after a dry tap aspiration had a sensitivity of 50.0% and a specificity of 95.8%. In 21% tissue biopsies led to the confirmation of PJI in patient with a high suspicion of PJI after dry tap aspiration. In patients with an inconclusive synovial fluid aspiration result the addition of tissue biopsies led to a change in treatment in 14%. In 212 cases revision surgery was performed, intraoperative tissue cultures had a sensitivity and specificity of 83.3% and 99.3%. Conclusions. Diagnosing PJI can be troublesome, especially if synovial fluid aspiration provides a dry tap. Tissue biopsy cultures in patients with a high suspicion of PJI after dry tap aspiration is a feasible way to confirm PJI, in 21% of patients PJI could be confirmed after dry tap aspiration. Ruling out PJI by means of a biopsy after a dry tap aspiration is less successful due to its low sensitivity. Tissue biopsies after an inconclusive aspiration leads to clinically important treatment changes

Background. Postoperative dislocation is one of the main surgical complications and the primary cause for revision surgery after 2-stage implant exchange due to periprosthetic infection of a total hip arthroplasty. Objective. The aims of our study were (1) to determine the incidence of dislocation after two-stage THA reimplantation without spacer placement, (2) to evaluate relevant risk factors for dislocation and (3) to assess the final functional outcome of those patients. Method. We prospectively analyzed 187 patients who underwent a two-stage total hip arthroplasty (THA) revision after being diagnosed with periprosthetic joint infection (PJI) from 2013 to 2019. The mean duration of follow-up was 54.2 ± 24.9 months (>36 months). The incidence of postoperative dislocation and subsequent revision was estimated through Kaplan-Meier curves and potential risk factors were identified using Cox hazard regression. The functional outcome of the patients was assessed using the modified Harris Hip Score (mHHS). Results. The estimated cumulative dislocation-free survival was 87.2% (95% CI: 81.2%-91.3%) with an estimated 10% and 12% risk for dislocation within the first 6 and 12 months, respectively. The use of a dual-mobility construct had no significant impact on the dislocation rate. Increasing body mass index (BMI) (HR=1.11, 95% CI: 1.02-1.19, p=0.011), abductor mechanism impairment (HR=2.85, 95% CI: 1.01-8.01, p=0.047), the extent of elongation of the affected extremity between stages (HR=1.04, 95% CI: 1.01-1.07, p=0.017), the final leg length discrepancy (HR=1.04, 95% CI: 1.01-1.08, p=0.018) and PJI recurrence (HR=2.76, 95% CI: 1.00-7.62, p=0.049) were found to be significant risk factors for dislocation. Overall revision rates were 17% after THA reimplantation. Dislocated hips were 62% more likely to undergo re-revision surgery (p<0.001, Log-rank= 78.05). A significant average increase of 30 points in mHHS scores after second-stage reimplantation (p=0.001, Wilcoxon-rank) was recorded, but no difference was noted in the final HHS measurements between stable and dislocated hips. Conclusion. Dislocation rates after 2-stage THA reimplantation for PJI remain high, especially regarding overweight or re-infected patients. Careful leg length restoration and an intact abductor mechanism seem critical to ensure stability in these complex patients

Aim. As the number of performed total hip arthroplasties (THA) and total knee arthroplasties (TKA) has increased over the years, revision surgeries are expected to increase as well. Revision surgeries are associated with a longer operating room time, prolonged length of stay (LOS), and more frequent complications. Postoperative hematomas are a major reason for wound healing disturbances and periprosthetic joint infections (PJI). We aimed to systematically assess the use and safety of a microporous polysaccharide hemosphere (MPH) in revision THA and TKA. We focused on the risk reduction of further revision surgeries in case of wound healing disorders and hematoma, transfusion of packed red blood cells (PRBC), loss of hemoglobin (hb) and mean LOS following the use of MPH. Method. Our prospective study includes 89 patients who underwent revision surgery after THA and TKA with application of MPH and were compared to 102 patients who did not receive MPH and underwent revision surgery after THA and TKA. Five grams of MPH. 1. were applied periarticular before fascia closure and to the subcutaneous soft tissue. The follow-up was conducted in daily clinical visits during the inpatient stay and three months postoperatively in our outpatient clinic. Repeated revision surgery was performed in case of prolonged secretion (>10 days) or clinical suspicion of infection. After matching the cohorts the outcomes were statistically analyzed using paired methods. Results. A significantly lower odds ratio for repeat revisions was found for the MPH cohort (OR=0.312; 95%-CI 0.090, 0.893; p=0.027). Differences between pre- and postoperative hb levels, LOS and transfusions of PRBC did not reach significance. No intra- or postoperative complications to MPH occurred. Moreover, no infection relapse occurred after applying MPH. Conclusions. Routine use of MPH in revision arthroplasty management after TKA and THA appears to be safe and an effective way to support hemostasis, with no observed adverse events related to MPH use. There were noticeably less hematomas and revision surgeries in the MPH group. 1. Arista BD, Franklin Lakes, NJ, USA