Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 – 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

Open debridement and Outerbridge and Kashiwagi debridement arthroplasty (OK procedure) are common surgical treatments for elbow arthritis. However, the literature contains little information on the long-term survivorship of these procedures. The purpose of this study was to determine the survivorship after elbow debridement techniques until conversion to total elbow arthroplasty and revision surgery. We performed a retrospective chart review of patients who underwent open elbow surgical debridement (open debridement, OK procedure) between 2000 and 2015. Patients were diagnosed with primary elbow osteoarthritis, post-traumatic arthritis, or inflammatory arthritis. A total of 320 patients had primary surgery including open debridement (n=142) and OK procedure (n=178), and of these 33 patients required a secondary revision surgery (open debridement, n=14 and OK procedure, n=19). The average follow-up time was 11.5 years (5.5 - 21.5 years). Survivorship was analyzed with Kaplan-Meier curves and Log Rank test. A Cox proportional hazards model was used assess the likelihood of conversion to total elbow arthroplasty or revision surgery while adjusting for covariates (age, gender, diagnosis). Significance was set p<0.05. Kaplan-Meier survival curves showed open debridement was 100.00% at 1 year, 99.25% at 5 years, and 98.49% at 10 years and for OK procedure 100.00% at 1 year, 98.80% at 5 years, 97.97% at 10 years (p=0.87) for conversion to total elbow arthroplasty. There was no difference in survivorship between procedures after adjusting for significant covariates with the cox proportional hazard model. The rate of revision for open debridement and OK procedure was similar at 11.31% rand 11.48% after 10 years respectively. There were higher rates of revision surgery in patients with open debridement (hazard ratio, 4.84 CI 1.29 - 18.17, p = 0.019) compared to OK procedure after adjusting for covariates. We also performed a stratified analysis with radiographic severity as an effect modifier and showed grade 3 arthritis did better with the OK procedure compared to open debridement for survivorship until revision surgery (p=0.05). However, this difference was not found for grade 1 or grade 2 arthritis. This may suggest that performing the OK procedure for more severe grade 3 arthritis could decrease reoperation rates. Further investigations are needed to better understand the indications for each surgical technique. This study is the largest cohort of open debridement and OK procedure with long term follow-up. We showed that open elbow debridement and the OK procedure have excellent survivorship until conversion to total elbow arthroplasty and are viable options in the treatment of primary elbow osteoarthritis and post traumatic cases. The OK procedure also has lower rates of revision surgery than open debridement, especially with more severe radiographic arthritis

To reveal if patient reported knee-related pain, function, quality of life, general health and satisfaction at one year after primary total knee arthroplasty (TKA) is different between patients not being subject to revision surgery and those having had early treatment with open debridement and exchange of the tibial insert for postoperative PJI. The Swedish Knee Arthroplasty Register was used to identify 50 patients in the region of Skane that had a primary TKA during the years 2008 – 2012 and within 6 months were revised with open debridement and exchange of the tibial insert due to suspected or verified PJI. Only patients without further revisions were included. Patient reported outcome measurements (PROM) were obtained preoperatively and 1 year postoperatively and included knee related pain, function, quality of life using the Knee injury and Osteoarthritis Outcome Score (KOOS), general health using the EQ-VAS as well as satisfaction with the surgery. The scores were compared to those reported by 3,913 patients having a TKA during the same time but not revised during the first year. Welch's t-test and the Chi2-test were used in statistical analysis. Compared to the controls the infected patients were older (mean age 72 vs 69 years, p = 0.04) and were more morbid (ASA 3; 14/50 patients vs 14%, p = 0.02). The preoperative PROM data were similar. Complete 1 year PROM data was available for 31 of the patients. Those patients reported somewhat worse outcome one year postoperatively than the controls with statistically and clinically significant differences in general health (mean 61 vs 76, p=0.002), KOOS ADL (mean 65 vs 76, p=0.03) and knee related quality of life (mean 51 vs 63, p=0.02) with large variations on individual level. Just over half of the patients (17/29) treated for PJI were very satisfied or satisfied with the surgery compared to 79% of the controls. Patients treated with open debridement and exchange of the tibial insert due to early PJI after primary TKA reported less beneficial postoperative outcome than those without revision surgery during the first postoperative year but with large individual variations

Sternoclavicular joint infections are uncommon but severe and complex condition usually in medically complex and compromised hosts. These infections are challenging to treat with risks of infection extending into the mediastinal structures and surgical drainage is often faced with problems of multiple unplanned returns to theatre, chronic non-healing wounds that turn into sinus and the risk of significant clinical escalation and death. Percutaneous aspirations or small incision drainage often provide inadequate drainage and failed control of infection, while open drainage and washout require multidisciplinary support, due to the close proximity of the mediastinal structures and the great vessels as well as failure to heal the wounds and creation of chronic wound or sinus. We present our series of 8 cases over 6 years where we used the plan of open debridement of the Sternoclavicular joint with medial end of clavicle excision to allow adequate drainage. The surgical incision was not closed primarily, and a suction vacuum dressing was applied until the infection was contained on clinical and laboratory parameters. After the infection was deemed contained, the surgical incision was closed by local muscle flap by transferring the medial upper sternal head of the Pectoralis Major muscle to fill in the sternoclavicular joint defect. This technique provided a consistent and reliable way to overcome the infection and have the wound definitively closed that required no secondary procedures after the flap surgery and no recurrence of infections so far. We suggest that open and adequate drainage of Sternoclavicular joint staged with vacuum dressing followed by pectoralis major local flap is a reliable technique for achieving control of infection and wound closure for these challenging infections

Periprosthetic joint infection (PJI) is a major complication affecting >1% of all total knee arthroplasties, with compromise in patient function and high rates of morbidity and mortality. There are also major socioeconomic implications. Diagnosis is based on a combination of clinical features, laboratory tests (including serum and articular samples) and diagnostic imaging. Once confirmed, prompt management is required to prevent propagation of the infection and further local damage. Non-operative measures include patient resuscitation, systemic antibiotics, and wound management, but operative intervention is usually required. Definitive surgical management requires open irrigation and debridement of the operative site, with or without exchange arthroplasty in either a single or two-stage approach. In all options, the patient's fitness, comorbidities and willingness for further surgery should be considered, and full intended benefits and complications openly discussed. Late infection almost invariably leads to implant removal but early infections and acute haematogenous infections can be managed with implant retention – the challenge is to retain the original implant, having eradicated infection and restored full function. Debridement with component retention: Open debridement is indicated for acute postoperative infections or acute haematogenous infections with previously well-functioning joints. To proceed with this management option the following criteria must be met: short duration of symptoms - ideally less than 2–3 weeks but up to 6; well-fixed and well-positioned prostheses; healthy surrounding soft tissues. Open debridement is therefore not an appropriate course of management if symptoms have been prolonged – greater than 6 weeks, if there is a poor soft tissue envelope and scarring, or if a revision arthroplasty would be more appropriate due to loosening or malposition of the implant. It is well documented in the literature that there is an inverse relationship between the duration of symptoms and the success of a debridement. It is thought that as the duration of symptoms increases, other factors such as patient comorbidities, soft tissue status and organism virulence play an increasingly important role in determining the outcome. There is a caveat. Based on our learning in the hip, when we see an acute infection where periprosthetic implants are used, it is much easier to use this time-limited opportunity to remove the implants and the associated biofilm and do a single-stage revision instead of just doing a debridement and a change of insert. This will clearly be experience and prosthesis-dependent but if the cementless implant is easy to remove, then it should be explanted. One critical aspect of this procedure is to use one set of instruments and drapes for the debridement and to then implant the new mobile parts and close using fresh drapes and clean instruments. Units that have gained expertise in single-stage revision will find this easier to do. After a debridement, irrigation, and change of insert, patients continue on intravenous antibiotics until appropriate cultures are available. Our multidisciplinary team and infectious disease experts then take over and will dictate antibiotic therapy thereafter. This is typically continued for a minimum of three months. Patients are monitored clinically, serologically, and particularly in relation to nutritional markers and general wellbeing. Antibiotics are stopped when the patients reach a stable level and are well in themselves. All patients are advised to re-present if they have an increase in pain or they feel unwell

Infection is a potentially disastrous complication of total knee arthroplasty (TKA). Although advances in surgical technique and antibiotic prophylaxis have reduced the incidence of infection to approximately 1% in primary TKA, there is still a substantial number of patients. Treatment options include antibiotic suppression, irrigation and debridement with component retention (with or without polyethylene exchange), one-stage or two-stage revision, resection arthroplasty and rarely arthrodesis or amputation. Salvage of prostheses has always been associated with low rates of success. It was reported a success rate of 27% for open debridement. It is suitable for selective cases where infection occurs within the first 4–6 weeks of primary TKA or in the setting of acute hematogenous gram positive infection with stable implants. With the advances in arthroscopic technique, arthroscopy after TKA has become an accepted method to assess and manage the complications of TKA. Arthroscopic treatment for infected TKA was reported and the successful rate was similar or better than open debridement in selected situations. We used arthroscopic debridement combined with continuous antibiotic irrigation and suction to treat acute presentation of infected TKA with acceptable result. From 2010∼2013, we has performed arthroscopic debridement and continuous antibiotic irrigation system for seven patients with infected TKA. All of the seven patients had no open wounds nor sinuses and no radiological evidence of prosthetic instability or evidence of osteomyelitis. Most of the surgical intervention was performed within two weeks from the onset of symptoms. Arthroscopic debridement was performed with a shaver using a multiportal technique (anterolateral, anteromedial, superolateral, superomedial, posterolateral, posteromedial) and a continuous antibiotic irrigation system was used to dilutes concentration of the causative microorganism and keep high local bactericidal concentration of antibiotics. We evaluated the efficacy by using follow up of the C-reactve protein (CRP) test, erythrocyte sedimentation rate (ESR) test and physical examination. Successful treatment was defined as prosthesis retention without recurrent infection by the final follow-up. Six of seven infected TKA were cured without recurrence at a mean follow-up of 23 months (range, 6–41 months). One case with rheumatoid arthritis under long-term steroid therapy had recurred after episode of upper respiratory tract infection for 3 times. However, the infection was controlled by arthroscopic debridement and retention of the prosthesis was achieved. We emphasize the importance of posterior portal to ensure adequate arthroscopic debridement. It is imperative to make early diagnosis and treatment for infected TKA. We should make more effort to preserve the prosthesis in acute infection(within 2 weeks). With the advantage of minimal morbidity, arthroscopic treatement shoulder be an alternative to open debridement

Background. Septic knee arthritis is one of the most serious complications after total knee arthroplasty (TKA), and the effectiveness of its treatment affects the patient's quality of life. In our super-aging society, the frequency of TKA in the elderly, often combined with various comorbidities, is increasing. Careful management should be considerd during the management of septic arthritis after TKA in these patients. Purpose. To analyze the clinical features and outcomes of septic arthritis after TKA in our institution. Materials and Methods. Between April 1999 and March 2014, 534 TKAs (osteoarthritis [OA]; 381, rheumatoid arthritis [RA]; 154) were performed. Of these patients, 8 with post-operative infected TKA were retrospectively surveyed. Results. The TKA-associated infection rates were 0.83% (0.35%, OA; 1.7%, RA) during the study period. Five male and 3 female patients were included, with a mean age of 68 years (range, 39–88 years) and primary diagnoses of OA (5) and RA (3). Malignant rheumatoid arthritis (MRA) was present in 1 patient. The infection was affected by a comorbidity in 2 (diabetes mellitus and mixed connective tissue disease). Microorganisms were detectable in 7 patients (methicillin-resistant Staphylococcus aureus [MRSA], 1; methicillin-sensitive Staphylococcus aureus, 2; Streptococcus pyogens, 1; Streptococcus oralis, 1; Escherichia coli, 1; Staphylococcus epidermidis, 1; and unknown, 1) (Fig. 1). The use of the Segawa/Leone classification resulted in 5 patients with type III (acute hematogenous) and 3 with type IV (late) infections. Four patients with type III (80%) infection underwent open debridement, continuous irrigation, and successful implant retention (Fig. 2). The MRA patient had type III infection and an MRSA infection that was treated with two-stage revision, but the infection recurred. We could not perform a re-implantation, and resection arthroplasty was needed. Arthroscopic irrigation in 1 patient with type III infection ended in failure, and open debridement was required. We attempted to retain the implant in 1 patient with type IV infection, but implant removal was required. Three patients with type IV infection underwent two-stage revision successfully. Discussion. The post-TKA infection rate was 0.83% in our institution. Of the implants, 50% (type III, 80%; type IV, 0%) were successfully retained. Early open debridement and irrigation are important for implant retention in patients with infected TKAs, while arthroscopic debridement does not appear to be effective for infected TKA. Implant retention was difficult in the presence of resistant microorganisms. Two-stage revision was required in patients with type IV infection, with a success rate of 75%

In 2019, the incidence of fractures were 178 million globally, South Africa accounting for close to 600 000 of these fractures, an 18.53% increase since 1990. South Africa does not have the public infrastructure to adequately facilitate the optimal surgical management of this burden. This forces intensive labour practices among orthopaedic surgeons, often performing complex surgeries throughout the night. There is a direct correlation between “after-hour”operations and the increase in morbidities. A retrospective review of the orthopaedic surgical cases and orthopaedic surgical emergencies done at a tertiary institution in Johannesburg between 8th of August 2021 to 12th December 2022. The nature of the orthopaedic interventions, the date of booking of the surgical procedures, date of surgical procedures, as well as start and end time of the orthopaedic interventions were analysed. “After-Hours” orthopaedic interventions were defined as interventions done between 16:00 and 07:00. Orthopaedic emergencies were defined as: Open fracture debridements, external Fixator insertion, arthrotomies, fasciotomies and the insertion of steinmann pins. 1483 (27.92%) of 5310 operative cases done on the emergency board were orthopaedic cases. 1098 (74.04%) hardware-related cases and 535 (36.08%) orthopaedic emergencies were done. 854 (57.58%) cases were done “After-Hours” of which 433 (29.20%) cases were done during “Dead-Hours” (23:00–07:00). Of these 433 cases, only 173 (39.95%) were true orthopaedic emergencies. Although the proportion of emergencies done after hours were greater than during working hours, there is still a large proportion of intricate orthopaedic cases done between 16:00– 07:00 that should not be prioritized, due to an associated higher morbidity. Enhanced strategic planning is advisable in future in order to prioritize complex hardware cases during working hours, and due to the burden, prioritize minor relooks and simple skin- grafts for the latter aspects of the night. A dedicated Orthopaedic Trauma theatre is recommended

Prosthetic joint infections (PJI) caused by Streptococcus species are relatively common. The aim of our study was to assess outcome after treatment for early and late PJI with Streptococcus species after a follow-up of two years. For this study we retrospectively included all patients with primary or revision total knee arthroplasty (TKA) or total hip (THA) arthroplasty, a minimum of two periprosthetic tissue cultures positive for Streptococcus species and a minimum follow-up of one year. According to international guidelines patients were classified as having early or late PJI. All patients with an early PJI were treated according to a standard treatment protocol, i.e. debridement and retention of the prosthesis, followed by adequate antibiotic therapy. Patients with late PJI underwent a debridement followed by adequate antibiotic therapy or joint revision. Patients’ hospital records were reviewed and we evaluated the status of the original prosthesis after an infection. Forty cases were included; 24 early and 16 late PJI. For early PJI, open debridement was performed in all patients, after a mean of 19 (range: 9 – 80) days. At final follow-up 21 prostheses (88%) were still in situ and without clinical signs of infection. Eight cases (41%) of late PJI were successfully treated with debridement and retention. Nine patients (59%) underwent a one- or two-stage revision. At final follow-up 16 patients (100%) with late PJI had a prosthesis in situ. Streptococcus dysgalactiae species accounted for more than 50% of the early infections, followed by Streptococcus agalactiae with 30%. In case of PJI with Streptococcus species open debridement and retention of the prosthesis should be performed followed by adequate and long-term antibiotic treatment. As expected, the retention rate for early PJI is much higher than that for late PJI

Introduction. Up to 2% of total hip arthroplasties (THA) are still complicated by infection. This leads to dissatisfied patients with poor function, and has far-reaching social and economic consequences. The challenge in these cases is the eradication of infection, the restoration of full function and the prevention of recurrence. We report the outcome of early aggressive debridement in the acutely infected THA. Methods. We studied 28 consecutive patients referred with acutely infected THA (18 primaries, 10 revisions) which occurred within 6 weeks of the index operation or of haematogenous spread between 1999 and 2006. Microbiology confirmed bacterial colonisation in all cases with 20 early post-operative infections and 8 cases of acute haematogenous spread. Patients with a cemented THA underwent aggressive open debridement, a thorough synovectomy and exchange of all mobile parts. Uncemented THA were treated as a single stage revision with removal of all implants, aggressive debridement and re-implantation of new prosthesis. Antibiotics were continued in all cases until inflammatory markers and the plasma albumin concentration returned to within normal limits. Results. Ten patients required multiple washouts. 7 patients needed a two stage revision. 21 patients returned to their expected functional level without removal of the implants and with no radiographic evidence of prosthetic failure. At a minimum 2 years follow-up, we had a 75% infection control rate. The outcome was significantly better in patients treated in the first 120 hours after presentation. Discussion and Conclusion. Our data suggests that there is a role for early aggressive open debridement in acute infections after THA with an excellent chance of eradicating infection

Aim. To review the outcome of deep prosthetic infection in patients following hip hemiarthroplasty surgery. Method. A retrospective case-note analysis was performed of deep infection coded hip hemiarthroplasty patients between 2004–2009. Patients were selected when there was proven microbiology from deep wound swabs or tissue specimens. Results. Deep infection developed in 14 of 1428 hemiarthroplasties. The mean age at time of fracture was 83 (71–93). There was a 12:2 female to male ratio. Eleven of the 14 cases had an American Society of Anaesthesiologists (ASA) score of three or four. Eight infections were due to Staphylococcus aureus, of which 6 were due to MRSA, which accounted for 43% of infections overall. There was no significant correlation between pathogen and success of treatment. Eight of the 14 hips were treated with open debridement and washout with implant retention. This was successful in 4 hips (50%). Infection recurred in 4 hips, one of which was revised to total hip replacement. The remaining 3 hips with recurrent infection were treated with excision arthroplasty. Three of the 14 hips were treated initially with excision arthroplasty. One required a further debridement and another required 3 debridements to control infection following implant removal. In 2 hips, a single stage revision to total hip replacement was performed. One of these developed recurrent infection, which was treated successfully with open debridement and washout. In one hip, no further surgery was performed. The 90-day mortality for patients with infected hemiarthroplasty was 36%. Conclusion. Deep infection following hemiarthroplasty of the hip has serious consequences and high mortality at 90 days. In our study sample, recurrence of infection was common and at least half required multiple operations. This study highlights the importance of infection prevention to reduce the morbidity and mortality following hip fracture surgery

Purpose. Management and outcomes of fungal periprosthetic joint infection (PJI) remain unclear due to its rarity. Although two-stage exchange arthroplasty is considered a treatment of choice for its chronic features, there is no consensus for local use of antifungal agent at the 1st stage surgery. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer in two-stage exchange arthroplasty against chronic fungal PJIs after total knee arthroplasty (TKA). Methods. Nine patients who were diagnosed and treated for chronic fungal PJIs after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, amphotericin-impregnated cement spacer was inserted for all patients. Systemic antifungal medication was used during the interval between two stage operations. Patients were followed up for more than 2 years after exchange arthroplasty and their medical records were reviewed. Results. The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, 5 to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by preoperative joint aspiration culture in 6 cases. For the other 3 cases, it was confirmed by open debridement tissue culture. All infections were caused by Candida parapsilosis except for one case which was caused by Candida pelliculosa. The average number of operations before exchange arthroplasty to solve the infection was 2.7 times (range, 1 to 5 times). Average duration of antifungal agent use confirmed by sensitivity test was 7 months (range, 4 to 15 months). Mean interval between two stage operation was 6 months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months). Conclusions. Due to its ill-defined symptoms and inconclusive blood test, fungal PJI after TKA is difficult to diagnose and has a prolonged clinical course. Two-stage exchange arthroplasty with antifungal-impregnated cement spacer is a very effective strategy with excellent outcome

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

Background. Infection is one of the most severe comlications of the total arthroplasty. We sometimes encounter cases, which are very hard to finish repeated recurrence. Usage of steroids, immunosuppressants, and biologics would possibly effect to the incidence of the prosthetic infection and to the result of its treatment. Biologics have drastically decreased the number of the total arthoplasic patients, on the other hand, we must be more careful about the infectious conditions. For the infection two stage revision surgery; first removal and antibiotics cement spacer insertion then reimplantation later; is often chosen but sometimes one time antibiotics cement spacer cannot stop the infection and requires multi times spacer insertion. In those cases the dead spaces, poor blood supply and tight skin could be the cause of the recurrence. For these cases we had been performing musclo-cutaneal flap and successfully finish the infection. Objectives. Our objectives are to review infection cases treated with musclo-cutaneal flap and compare with treatment without it. Methods: Since 2004 to 2013, 6 infection cases were treated. Our standard policy is 2-staged revision. In the first surgery, the prosthesis was removed and cement spacer was inserted. If no evidence of the remained infection was found reimplantation would be done in the second surgery. Otherwise debridement and cement spacer were repeated. In 3 cases, the infection could be finished without musclo-cutaneal flap but in 3 cases musclo-cutaneal flap was finally done then the infection was finished. The clinical courses were reviewed. Results. Case 1. After right hip revision, fistula formation was occurred. Later, enterococcus fecalis was detected. Six times cement spacer insertion was performed. But fistula was remained. Musclo-cutaneal flap of sartorius muscle was performed. No fistula was seen after that. Case 2. Fistula was appeared 3 years after hip replacement. The culture was negative. New prosthesis insertion was done after one time spacer treatment then the infection was controlled. Case 3. Six weeks after primary hip replacement, fistula was appeared. MRSA was found. Three times antibiotic spacer insertions were done then re-implantation was successfully done. Case 4. Three weeks after total knee replacement, the wound became lose and MRSA was found. The wound was communicated with the joint and the patient had general weakness, so musclo-cutaneal flap was done in one time. No recurrence was seen. Case 5. Two weeks after total hip replacement, MRSA superficial infection was found. Wound washing and both injection and oral antibiotics were used. Case 6. This patient was sent from a certain hospital after 3 times open debridement. MRSA was still positive. One time antibiotics spacer was done, and then revision with musculo-cutaneal flap of lateral vastus muscle was performed. No recurrence is seen so far. In all flap cases, infection was finished in our case. On the other hand, the surgical invasion was much bigger. So we can take musculo cutaneal flap into consideration to overcome the recurent infection

Gold standard for the management of non-union is open surgical debridement, stabilisation, and autologous bone grafting. LIPUS is becoming more popular, yet the evidence is still inconclusive. LIPUS involves the use of ultrasound at the fracture site with little risk to the patient. The purpose of this study was to assess effectiveness and cost benefit of LIPUS in the management of non-unions post sustaining an open fracture. We retrospectively reviewed 29 patients with open fractures with established non-union undergoing LIPUS since 2010 (4 females, mean age 48) range 3–27 months, mean 9 months, either post injury or last intervention. All were tertiary referrals, sustaining injuries to the following areas; Tibial 21, Femur 6, Humerus 2, Radius 1. Definitive fixation being; 9 TSF's, 11 IMN's, 9 plates. (undergoing a mean 2.4 procedures). Aside from sustaining an open fracture, 7 had risk factors for non-unions 5 smokers, 2 NSAID's. Failure of treatment was based on undertaking bone grafting. In 28 patients (1 lost to follow up) union was achieved in 71% (mean 157 days). All were screened for infection, 4 had organisms on enrichment culture. 8 (5 Gustillo Anderson Grade 3A/B) injuries did not show evidence of callus formation, LIPUS was discontinued and grafting performed. Open fractures were graded as; 7 Grade 1, 4 Grade 2, 8 Grade 3A, 10 Grade 3B being received. Of these; 20 underwent primary closure, 6 free flaps and 3 SSG. The cost of LIPUS is approx £2500, compared bone grafting using autologous iliac crest graft with no medical comorbidities of £3715. This case series further supports union rates after LIPUS. Cost and morbidity benefit of utilising LIPUS over opting for bone grafting initially is £1215 per patient. Whilst autologous bone grafting is currently the gold standard, it is not without morbidity. We achieved union rates of 71% despite a number of patients having recognised risk factors, showing that LIPUS is a useful resource in the management of non-union

The role of magnetic resonance arthrography (MRA) in the evaluation of patients with femoroacetabular impingement (FAI) to assess femoral head-neck junction asphericity and labral pathology is well established. However, in our experience, the presence of acetabular cysts on MRA, which may signify underlying full thickness articular cartilage delamination and progression towards arthropathy, is also an important feature. We retrospectively reviewed 142 hips (mean age 32 years, 47 men, 95 women), correlating the findings on MRA with those found at the time of open surgical hip debridement to ascertain the prevalence of acetabular cysts and the association with underlying acetabular changes. Fourteen MRAs demonstrated features consistent with underlying acetabular cystic change. At the time of surgery, this was confirmed in eleven cases that demonstrated a full thickness articular chondral flap in all cases and an underlying acetabular cyst. The sensitivity, specificity, positive predictive value and negative predictive value of MRA in relation to acetabular cysts was 55%, 97.5%, 78.5% and 92.9% respectively. We believe acetabular cysts on MRA to be a significant finding. Such patients are likely to have an associated full thickness chondral lesion and features of early degenerative change, influencing outcome and prognosis. Our clinical practice has changed to reflect this finding. For those patients with cysts on MRA, we offer open debridement only to the severely affected young and favour arthroscopic debridement in older patients with smaller cams. We believe hip preservation surgeons should be aware of the significance of acetabular cysts and be prepared to adjust treatment accordingly

The role of magnetic resonance arthrography (MRA) in the evaluation of patients with femeroacetabular impingement (FAI) to assess femoral head-neck junction asphericity and labral pathology is well established. However, in our experience the presence of acetabular cysts on MRA, which may signify underlying full thickness articular cartilage delamination and progression towards arthropathy, is also an important feature. We retrospectively reviewed 142 hips (mean age 32 years, 47 men, 95 women), correlating the findings on MRA with those found at the time of open surgical hip debridement to ascertain the prevalence of acetabular cysts and the association with underlying acetabular changes. Fifteen MRA's demonstrated features consistent with underlying acetabular cystic change. At the time of surgery, this was confirmed in eleven cases that demonstrated a full thickness articular chondral flap (carpet lesion) and an underlying acetabular cyst. The sensitivity, specificity, positive predictive value and negative predictive value of MRA in relation to acetabular cysts was 55%, 96.7%, 73.3% and 92.9% respectively. We believe acetabular cysts on MRA to be a significant finding. Such patients are likely to have an associated full thickness chondral lesion and features of early degenerative change, influencing outcome and prognosis. Our clinical practise has changed to reflect this finding. For those patients with cysts on MRA, we are less likely to offer open debridement and favour arthroscopic intervention followed by arthroplasty when symptoms dictate. We believe hip preservation surgeons should be aware of the significance of acetabular cysts and be prepared to adjust treatment options accordingly

Infection of total hip replacement is a disaster, with a quoted incidence of 1-2%. Anecdotal evidence has led many to believe that aggressive management of early infection following hip replacement can prevent failure. As yet, there is no firm evidence. We have reviewed 20 consecutive cases of early infection (<6 weeks post-op) treated by open debridement and washout. The cases were 19 total hip replacements and 1 hemiarthroplasty. All had prolonged wound I discharge and elevated inflammatory parameters. No differentiation was made between superficial and deep infections because at this stage the deep fascia had not yet healed. 13 cases had positive cultures (6 staphylococcus, 5 coagulase negative staphylococcus, 1 coliform, 1 streptococcus). 7 cases had either negative cultures or mixed growth, but were clinically infected. Intravenous antibiotics were given after debridement until the wound healed. Thirteen (65%) were clinically and radiologically free of infection at a minimum of 1 year follow-up. Failure to eradicate infection was treated by revision surgery and this was performed in 4 patients. Of the remaining 3 patients, one underwent excision arthroplasty, one was infected but refused surgery and one was infected but medically unfit for surgery. There is no control group, but it would be ethically very difficult to organise. As expected, we had small numbers and a mixed collection of organisms, so statistical comparisons are limited. In conclusion, these patients represent a very high risk of ongoing infection. 13 hips (65%) had no evidence of ongoing infection at a minimum of 1 year follow up. This study supports aggressive surgical management of early infection following hip replacements. Eradication of early infection can be achieved without removal of the implant

Introduction:. Unicompartmental knee arthroplasty (UKA) is becoming an increasingly popular option in single compartment osteoarthritis. As a result, diverse second operations including revisions to total knee arthroplasty (TKA) will also increase. The objective of this study is to investigate the distribution of causes of second operations after UKA. Methods:. We retrospectively reviewed 695 UKAs performed on 597 patients between January 2003 and December 2011. Except in one case, all UKAs were replaced at the medial compartment of the knee. The UKAs were performed on 559 (80.4%) women's knees and 136 (19.6%) men's knees. The mean age at the time of UKA was 61.5 years. The mobile-bearing designs were those that were predominantly implanted (n = 628 mobile, 90.2%; n = 67 fixed). The mean interval between UKA and second operation was 14.1 months. Results:. In our study, the burden of a second operation after the initial UKA was 7.3%, and the total number of second operations was 51 (n = 45 mobile, n = 6 fixed). The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the meniscal bearing (34.8%), followed by component loosening (21.7%), the formation of a cement loose body (15.2%), unexplained pain (13%), infection (6.5%), periprosthetic fracture (4.3%), and others (4.4%). For the fixed-bearing UKA, the causes of a second operation were loosening (n = 2), unexplained pain (n = 2), and bearing wear (n = 1). The main causes of either a revision UKA or a conversion to TKA were multiform operations that included bricement, internal fixation for a periprosthetic fracture, isolated bearing changes, open debridement with bearing changes, or implant removal due to early infection. Conversions to TKA during the second operation were performed in 17 cases. Discussion and conclusion:. The most common cause of a second operation after a mobile-bearing UKA was the dislocation of the bearing, followed by component loosening and the formation of a cement loose body. After a fixed-bearing UKA, component loosening and unexplained pain were the most common. A cause-based approach to the primary and failed UKA may be helpful to minimize the possibility of a second operation and to give rise to a successful outcome of a revision TKA

The purpose of this study is to evaluate the indications and technique of hip arthroscopy for problems associated with total joint replacement. Materials and Methods:. Fifteen consecutive patients underwent arthroscopy post total hip replacement. Two cases had suspected sepsis unproven by aspiration but for medical reasons were unable to undergo arthrotomy. Two cases had intraarticular migration of a broken trochanteric wire and an additional case had progressive loosening of an acetabular screw into the articulation. The remaining 10 cases had persistent and debilitating pain despite negative diagnostic studies (aspiration, arthrogram, CT, etc). Results:. Two cases of joint sepsis were lavaged and debrided arthroscopically in addition to intravenous antibiotics without recurrent sepsis at 2-year follow up. Intraarticular metal fragments and a loose acetabular screw were successfully removed via arthroscopic means in 3 different hips. Ten cases had hip arthroscopy for persistent and debilitating pain despite negative radiographs and aspiration arthrogram. Findings included a loose acetabular component; corrosion at the interface of a metal-on-metal articulation; and 8 had dense scar tissue impingement at the head cup interface and synovitis. Four of those 8 had complete resolution of their symptoms, 3 went on to open arthrotomy, and one has had some improvement and chooses to decline further surgery. Discussion:. Arthroscopy is not a substitute for open hip debridement and/or resection arthroplasty. However, it is of value in difficult cases to improve diagnostic accuracy. This study demonstrates successful removal of wire, beads and a bone screw by arthroscopic means, thus reducing hospital costs and patient morbidity