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The Bone & Joint Journal
Vol. 103-B, Issue 11 | Pages 1678 - 1685
1 Nov 2021
Abdelaziz H Schröder M Shum Tien C Ibrahim K Gehrke T Salber J Citak M

Aims. One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions. Methods. In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups. Results. Patients who required resection of the proximal femur were found to have a higher all-cause re-revision rate (29.8% vs 10.5%; p = 0.018), largely due to reinfection (15.8% vs 0%; p = 0.003), and dislocation (8.8% vs 10.5%; p = 0.762), and showed higher rate of in-hospital wound haematoma requiring aspiration or evacuation (p = 0.013), and wound revision (p = 0.008). The use of of dual mobility components/constrained liner in the resection group was higher than that of controls (94.7% vs 36.8%; p < 0.001). The presence and removal of additional metal hardware (odds ratio (OR) = 7.2), a sinus tract (OR 4), ten years’ time interval between primary implantation and index infection (OR 3.3), and previous hip revision (OR 1.4) increased the risk of proximal femoral resection. A sinus tract (OR 9.2) and postoperative dislocation (OR 281.4) were associated with increased risk of subsequent re-revisions. Conclusion. Proximal femoral resection during one-stage revision hip arthroplasty for PJI may be required to reduce the risk of of recurrent or further infection. Patients with additional metalware needing removal or transcortical sinus tracts and chronic osteomyelitis are particularly at higher risk of needing proximal femoral excision. However, radical resection is associated with higher surgical complications and increased re-revision rates. The use of constrained acetabular liners and dual mobility components maintained an acceptable dislocation rate. These results, including identified risk factors, may aid in preoperative planning, patient consultation and consent, and intraoperative decision-making. Cite this article: Bone Joint J 2021;103-B(11):1678–1685


The Bone & Joint Journal
Vol. 103-B, Issue 9 | Pages 1464 - 1471
1 Sep 2021
Barker TP Steele N Swamy G Cook A Rai A Crawford R Lutchman L

Aims. Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471


The Bone & Joint Journal
Vol. 103-B, Issue 8 | Pages 1400 - 1404
1 Aug 2021
Sim FCJ Birley E Khan AL Loughenbury PR Millner P

Aims. The aim of this study was to determine whether there is an increased prevalence of scoliosis in patients who have suffered from a haematopoietic malignancy in childhood. Methods. Patients with a history of lymphoma or leukaemia with a current age between 12 and 25 years were identified from the regional paediatric oncology database. The medical records and radiological findings were reviewed, and any spinal deformity identified. The treatment of the malignancy and the spinal deformity, if any, was noted. Results. From a cohort of 346 patients, 19 (5.5%) had radiological evidence of scoliosis, defined as a Cobb angle of > 10°. A total of five patients (1.4% of the total cohort) had a Cobb angle of > 40°, all of whom had corrective surgery. No patient with scoliosis had other pathology as a possible cause of the scoliosis and all had been treated with high doses of steroids for leukaemia, either acute or chronic myeloid, or acute lymphoblastic. Conclusion. There is an increased prevalence of idiopathic-like scoliosis and larger curves (Cobb angle of > 40°) associated with childhood leukaemia, which has not been previously reported in the literature. Causative factors may relate to the underlying disease process and/or its treatment. Cite this article: Bone Joint J 2021;103-B(8):1400–1404


The Bone & Joint Journal
Vol. 100-B, Issue 5 | Pages 610 - 616
1 May 2018
Giannicola G Bullitta G Rotini R Murena L Blonna D Iapicca M Restuccia G Merolla G Fontana M Greco A Scacchi M Cinotti G

Aims. The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population. Patients and Methods. A total of 28 patients were operated on for primary DTTR reinsertions, including 21 male patients and seven female patients with a mean age of 45 years (14 to 76). Of these patients, 23 sustained an acute DTTR and five had a chronic injury. One patient had a non-simultaneous bilateral DTTR. Seven patients had DTTR-associated ipsilateral fracture or dislocation. Comorbidities were present in four patients. Surgical treatment included transosseous and suture-anchors reinsertion in 22 and seven DTTRs, respectively. The clinical evaluation was performed using Mayo Elbow Performance Score (MEPS), the modified American Shoulder and Elbow Surgeons Score (m-ASES), the Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), and the Medical Research Council (MRC) Scale. Results. A total of 27 patients (28 DTTRs) were available for review at a mean of 47.5 months (12 to 204). The mean MEPS, QuickDASH, and m-ASES scores were 94 (60 to 100), 10 (0 to 52), and 94 (58 to 100), respectively. Satisfactory results were observed in 26 cases (93%). Muscle strength was 5/5 and 4/5 in 18 and ten DTTRs, respectively. One patient with chronic renal failure experienced a traumatic rerupture of distal triceps. One patient (1 DTTR) experienced mild elbow stiffness. Conclusion. Primary repair of acute and chronic DTTRs in a general population yields satisfactory results in the majority of patients with a low rerupture rate. Cite this article: Bone Joint J 2018;100-B:610–16


The Bone & Joint Journal
Vol. 103-B, Issue 6 | Pages 1127 - 1132
1 Jun 2021
Gray J Welck M Cullen NP Singh D

Aims. To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle. Methods. We carried out a retrospective search of our records from 2000 to 2019 of patients seen in our adult tertiary referral foot and ankle unit with a diagnosis of functional dystonia. Results. A total of 29 patients were seen. A majority were female (n = 25) and the mean age of onset of symptoms was 35.3 years (13 to 71). The mean delay between onset and diagnosis was 7.1 years (0.5 to 25.0). Onset was acute in 25 patients and insidious in four. Of the 29 patients, 26 had a fixed dystonia and three had a spasmodic dystonia. Pain was a major symptom in all patients, with a coexisting diagnosis of chronic regional pain syndrome (CRPS) made in nine patients. Of 20 patients treated with Botox, only one had a good response. None of the 12 patients who underwent a surgical intervention at our unit or elsewhere reported a subjective overall improvement. After a mean follow-up of 3.2 years (1 to 12), four patients had improved, 17 had remained the same, and eight reported a deterioration in their condition. Conclusion. Patients with functional dystonia typically presented with a rapid onset of fixed deformity after a minor injury/event and pain out of proportion to the deformity. Referral to a neurologist to rule out neurological pathology is advocated, and further management should be carried out in a movement disorder clinic. Response to treatment (including Botulinum toxin (Botox) injections) is generally poor. Surgery in this group of patients is not recommended and may worsen the condition. The overall prognosis remains poor. Cite this article: Bone Joint J 2021;103-B(6):1127–1132


The Bone & Joint Journal
Vol. 102-B, Issue 3 | Pages 345 - 351
1 Mar 2020
Pitts C Alexander B Washington J Barranco H Patel R McGwin G Shah AB

Aims. Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods. We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results. Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion. We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351


The Bone & Joint Journal
Vol. 102-B, Issue 6 Supple A | Pages 170 - 175
1 Jun 2020
Chalmers BP Matrka AK Sems SA Abdel MP Sierra RJ Hanssen AD Pagnano MW Mabry TM Perry KI

Aims. Arthrodesis is rarely used as a salvage procedure for patients with a chronically infected total knee arthroplasty (TKA), and little information is available about the outcome. The aim of this study was to assess the reliability, durability, and safety of this procedure as the definitive treatment for complex, chronically infected TKA, in a current series of patients. Methods. We retrospectively identified 41 patients (41 TKAs) with a complex infected TKA, who were treated between 2002 and 2016 using a deliberate, two-stage knee arthrodesis. Their mean age was 64 years (34 to 88) and their mean body mass index (BMI) was 39 kg/m. 2. (25 to 79). The mean follow-up was four years (2 to 9). The extensor mechanism (EM) was deficient in 27 patients (66%) and flap cover was required in 14 (34%). Most patients were host grade B (56%) or C (29%), and limb grade 3 (71%), according to the classification of McPherson et al. A total of 12 patients (29%) had polymicrobial infections and 20 (49%) had multi-drug resistant organisms; fixation involved an intramedullary nail in 25 (61%), an external fixator in ten (24%), and dual plates in six (15%). Results. Survivorship free from amputation, persistent infection, and reoperation, other than removal of an external fixator, at five years was 95% (95% confidence interval (CI) 89% to 100%), 85% (95% CI 75% to 95%), and 64% (95% CI 46% to 82%), respectively. Reoperation, other than removal of an external fixator, occurred in 13 patients (32%). After the initial treatment, radiological nonunion developed in ten knees (24%). Nonunion was significantly correlated with persistent infection (p = 0.006) and external fixation (p = 0.005). Of those patients who achieved limb salvage, 34 (87%) remained mobile and 31 (79%) had ‘absent’ or ‘minimal’ pain ratings. Conclusion. Knee arthrodesis using a two-stage protocol achieved a survivorship free from amputation for persistent infection of 95% at five years with 87% of patients were mobile at final follow-up. However, early reoperation was common (32%). This is not surprising as this series included worst-case infected TKAs in which two-thirds of the patients had a disrupted EM, one-third required flap cover, and most had polymicrobial or multi-drug resistant organisms. Cite this article: Bone Joint J 2020;102-B(6 Supple A):170–175


The Bone & Joint Journal
Vol. 103-B, Issue 2 | Pages 234 - 244
1 Feb 2021
Gibb BP Hadjiargyrou M

Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics. Cite this article: Bone Joint J 2021;103-B(2):234–244


The Bone & Joint Journal
Vol. 100-B, Issue 11 | Pages 1482 - 1486
1 Nov 2018
Akgün D Müller M Perka C Winkler T

Aims. The aim of this study was to determine the prevalence and characteristics of C-reactive protein (CRP)-negative prosthetic joint infection (PJI) and evaluate the influence of the type of infecting organism on the CRP level. Patients and Methods. A retrospective analysis of all PJIs affecting the hip or knee that were diagnosed in our institution between March 2013 and December 2016 was performed. A total of 215 patients were included. Their mean age was 71 years (. sd. 11) and there were 118 women (55%). The median serum CRP levels were calculated for various species of organism and for patients with acute postoperative, acute haematogenous, and chronic infections. These were compared using the Kruskal–Wallis test, adjusting for multiple comparisons with Dunn’s test. The correlation between the number of positive cultures and serum CRP levels was estimated using Spearman correlation coefficient. Results. Preoperative CRP levels were normal (< 10 mg/l) in 77 patients (35.8%) with positive cultures. Low-virulent organisms were isolated in 66 PJIs (85.7%) with normal CRP levels. When grouping organisms by species, patients with an infection caused by Propionibacterium spp., coagulase-negative staphylococci (CNS), and Enterococcus faecalis had significantly lower median serum CRP levels (5.4 mg/l, 12.2 mg/l, and 23.7 mg/l, respectively), compared with those with infections caused by Staphylococcus aureus and Streptococcus spp. (194 mg/l and 89.3 mg/l, respectively; p < 0.001). Those with a chronic PJI had statistically lower median serum CRP levels (10.6 mg/l) than those with acute postoperative and acute haematogenous infections (83.7 mg/l and 149.4 mg/l, respectively; p < 0.001). There was a significant correlation between the number of positive cultures and serum CRP levels (Spearman correlation coefficient, 0.456; p < 0.001). Conclusion. The CRP level alone is not accurate as a screening tool for PJI and may yield high false-negative rates, especially if the causative organism has low virulence. Aspiration of the joint should be used for the diagnosis of PJI in patients with a chronic painful arthroplasty, irrespective of CRP level. Cite this article: Bone Joint J 2018;100-B:1482–86


Bone & Joint Research
Vol. 8, Issue 7 | Pages 313 - 322
1 Jul 2019
Hanberg P Lund A Søballe K Bue M

Objectives. Meropenem may be an important drug in the treatment of open tibial fractures and chronic osteomyelitis. Therefore, the objective of this study was to describe meropenem pharmacokinetics in plasma, subcutaneous adipose tissue (SCT), and cancellous bone using microdialysis in a porcine model. Methods. Six female pigs were assigned to receive 1000 mg of meropenem intravenously over five minutes. Measurements of meropenem were obtained from plasma, SCT, and cancellous bone for eight hours thereafter. Microdialysis was applied for sampling in solid tissues. The meropenem concentrations were determined using ultra-high-performance liquid chromatography. Results. The penetration of meropenem into cancellous bone, expressed as the ratio of plasma to cancellous bone area under the concentration-curve from zero to the last measured value, was incomplete and delayed. The time with concentration above the minimal inhibitory concentration (T. >MIC. ), for an MIC of 0.5 μg/ml, was shorter for cancellous bone in comparison with both plasma and SCT. For MICs above 0.5 μg/ml, T. >MIC. in cancellous bone was only shorter than SCT. Considering an MIC of 4 μg/ml, no animals achieved the target of 40% T. >MIC. in plasma and cancellous bone, while less than 20% achieved it in SCT. Conclusion. The main finding of this study was short T. >MIC. in cancellous bone after intravenous administration of 1000 mg meropenem. Consequently, in order to achieve sufficient tissue concentration in the cases of open tibial fractures and chronic osteomyelitis, supplemental application of meropenem may be necessary. Cite this article: P. Hanberg, A. Lund, K. Søballe, M. Bue. Single-dose pharmacokinetics of meropenem in porcine cancellous bone determined by microdialysis: An animal study. Bone Joint Res 2019;8:342–348. DOI: 10.1302/2046-3758.87.BJR-2018-0308.R1


The Bone & Joint Journal
Vol. 97-B, Issue 10_Supple_A | Pages 45 - 48
1 Oct 2015
Lavand'homme P Thienpont E

The patient with a painful arthritic knee awaiting total knee arthroplasty (TKA) requires a multidisciplinary approach. Optimal control of acute post-operative pain and the prevention of chronic persistent pain remains a challenge. The aim of this paper is to evaluate whether stratification of patients can help identify those who are at particular risk for severe acute or chronic pain. . Intense acute post-operative pain, which is itself a risk factor for chronic pain, is more common in younger, obese female patients and those suffering from central pain sensitisation. Pre-operative pain, in the knee or elsewhere in the body, predisposes to central sensitisation. Pain due to osteoarthritis of the knee may also trigger neuropathic pain and may be associated with chronic medication like opioids, leading to a state of nociceptive sensitisation called ‘opioid-induced hyperalgesia’. Finally, genetic and personality related risk factors may also put patients at a higher risk for the development of chronic pain. . Those identified as at risk for chronic pain would benefit from specific peri-operative management including reduction in opioid intake pre-operatively, the peri-operative use of antihyperalgesic drugs such as ketamine and gabapentinoids, and a close post-operative follow-up in a dedicated chronic pain clinic. Cite this article: Bone Joint J 2015;97-B(10 Suppl A):45–8


The Bone & Joint Journal
Vol. 103-B, Issue 1 | Pages 131 - 140
1 Jan 2021
Lai MKL Cheung PWH Samartzis D Karppinen J Cheung KMC Cheung JPY

Aims. To study the associations of lumbar developmental spinal stenosis (DSS) with low back pain (LBP), radicular leg pain, and disability. Methods. This was a cross-sectional study of 2,206 subjects along with L1-S1 axial and sagittal MRI. Clinical and radiological information regarding their demographics, workload, smoking habits, anteroposterior (AP) vertebral canal diameter, spondylolisthesis, and MRI changes were evaluated. Mann-Whitney U tests and chi-squared tests were conducted to search for differences between subjects with and without DSS. Associations of LBP and radicular pain reported within one month (30 days) and one year (365 days) of the MRI, with clinical and radiological information, were also investigated by utilizing univariate and multivariate logistic regressions. Results. Subjects with DSS had higher prevalence of radicular leg pain, more pain-related disability, and lower quality of life (all p < 0.05). Subjects with DSS had 1.5 (95% confidence interval (CI) 1.0 to 2.1; p = 0.027) and 1.8 (95% CI 1.3 to 2.6; p = 0.001) times higher odds of having radicular leg pain in the past month and the past year, respectively. However, DSS was not associated with LBP. Although, subjects with a spondylolisthesis had 1.7 (95% CI 1.1 to 2.5; p = 0.011) and 2.0 (95% CI 1.2 to 3.2; p = 0.008) times greater odds to experience LBP in the past month and the past year, respectively. Conclusion. This large-scale study identified DSS as a risk factor of acute and chronic radicular leg pain. DSS was seen in 6.9% of the study cohort and these patients had narrower spinal canals. Subjects with DSS had earlier onset of symptoms, more severe radicular leg pain, which lasted for longer and were more likely to have worse disability and poorer quality of life. In these patients there is an increased likelihood of nerve root compression due to a pre-existing narrowed canal, which is important when planning surgery as patients are likely to require multi-level decompression surgery. Cite this article: Bone Joint J 2021;103-B(1):131–140


The Bone & Joint Journal
Vol. 102-B, Issue 10 | Pages 1281 - 1288
3 Oct 2020
Chang JS Kayani B Plastow R Singh S Magan A Haddad FS

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management. Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury. This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients. Cite this article: Bone Joint J 2020;102-B(10):1281–1288


The Bone & Joint Journal
Vol. 101-B, Issue 2 | Pages 221 - 226
1 Feb 2019
Ryan SP DiLallo M Klement MR Luzzi AJ Chen AF Seyler TM

Aims. The aim of this study was to characterize the factors leading to transfemoral amputation after total knee arthroplasty (TKA), as well as the rates of mortality and functional independence after this procedure in these patients. Patients and Methods. This was a multicentre retrospective review with a prospective telephone survey for the assessment of function. All patients with a TKA who subsequently required transfemoral amputation between January 2001 and December 2015 were included. Demographic information, medical comorbidities, and postoperative mortality data were collected. A 19-item survey was used for the assessment of function in surviving patients. Results. A total of 111 patients were included. Their mean age was 61.0 years (42.0 to 88.0) at the time of TKA, with a subsequent mean of 3.7 operations (0 to 15) over a mean period of 6.1 years (0.05 to 30.1) before amputation. The indication for amputation was chronic infection in 97 patients (87.4%). The rate of five-year survival was 51.7%, and advanced age (p = 0.001) and renal failure (p = 0.045) were associated with an increased risk of mortality. Of the 62 surviving patients, 34 completed the survey; 32 (94.1%) owned a prosthesis but only 19 (55.9%) used it; 19 (55.9%) primarily used a wheelchair for mobility; 27 (79.5%) had phantom pain; and 16 (47.1%) required chronic pain medication. Only 18 patients (52.9%) were satisfied with the quality of life. Conclusion. Patients with complications after TKA, in whom transfemoral amputation is considered, should be made aware of the high rate of mortality and the poor functional outcome in the survivors. Alternative forms of treatment including arthrodesis of the knee should be investigated


The Bone & Joint Journal
Vol. 102-B, Issue 10 | Pages 1375 - 1383
3 Oct 2020
Zhang T Sze KY Peng ZW Cheung KMC Lui YF Wong YW Kwan KYH Cheung JPY

Aims. To investigate metallosis in patients with magnetically controlled growing rods (MCGRs) and characterize the metal particle profile of the tissues surrounding the rod. Methods. This was a prospective observational study of patients with early onset scoliosis (EOS) treated with MCGRs and undergoing rod exchange who were consecutively recruited between February 2019 and January 2020. Ten patients were recruited (mean age 12 years (SD 1.3); 2 M:8 F). The configurations of the MCGR were studied to reveal the distraction mechanisms, with crucial rod parts being the distractable piston rod and the magnetically driven rotor inside the barrel of the MCGR. Metal-on-metal contact in the form of ring-like wear marks on the piston was found on the distracted portion of the piston immediately outside the barrel opening (BO) through which the piston rod distracts. Biopsies of paraspinal muscles and control tissue samples were taken over and away from the wear marks, respectively. Spectral analyses of the rod alloy and biopsies were performed to reveal the metal constituents and concentrations. Histological analyses of the biopsies were performed with haematoxylin and eosin staining. Results. Titanium (Ti), vanadium (V), and neodymium (Nd) concentrations in the biopsies taken near the wear marks were found to be significantly higher than those in the control tissue samples. Significantly increased Nd concentrations were also found in the tissues near the barrel of the MCGR. Chronic inflammation was revealed by the histological studies with fibrosis and macrophage infiltration. Black particles were present within the macrophages in the fibrotic tissues. Conclusion. Ti and V were generated mainly at the BO due to metal-on-metal contact, whereas the Nd from the rotor of the MCGR is likely released from the BO during distraction sessions. Phagocytotic immune cells with black particles inside raise concern regarding the long-term implications of metallosis. Cite this article: Bone Joint J 2020;102-B(10):1375–1383


Bone & Joint Research
Vol. 10, Issue 4 | Pages 285 - 297
1 Apr 2021
Ji M Ryu HJ Hong JH

Rheumatoid arthritis (RA) is an autoimmune disease characterized by symmetrical and chronic polyarthritis. Fibroblast-like synoviocytes are mainly involved in joint inflammation and cartilage and bone destruction by inflammatory cytokines and matrix-degrading enzymes in RA. Approaches that induce various cellular growth alterations of synoviocytes are considered as potential strategies for treating RA. However, since synoviocytes play a critical role in RA, the mechanism and hyperplastic modulation of synoviocytes and their motility need to be addressed. In this review, we focus on the alteration of synoviocyte signalling and cell fate provided by signalling proteins, various antioxidant molecules, enzymes, compounds, clinical candidates, to understand the pathology of the synoviocytes, and finally to achieve developed therapeutic strategies of RA. Cite this article: Bone Joint Res 2021;10(4):285–297


The Bone & Joint Journal
Vol. 102-B, Issue 7 | Pages 959 - 964
1 Jul 2020
Malik AT Li M Khan SN Alexander JH Li D Scharschmidt TJ

Aims. Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs. Methods. The 2008-2014 Medicare 5% Standard Analytical Files (SAF5) were used to identify patients undergoing revision TJA under DRG codes 466, 467, or 468. Generalized linear regression models were built to assess the independent marginal cost-impact of patient, procedural, and geographic characteristics on 90-day costs. Results. A total of 9,263 patients (DRG-466 = 838, DRG-467 = 4,573, and DRG-468 = 3,842) undergoing revision TJA from 2008 to 2014 were included in the study. Undergoing revision for a dislocation (+$1,221), periprosthetic fracture (+$4,454), and prosthetic joint infection (+$5,268) were associated with higher 90-day costs. Among comorbidities, malnutrition (+$10,927), chronic liver disease (+$3,894), congestive heart failure (+$3,292), anaemia (+$3,149), and coagulopathy (+$2,997) had the highest marginal cost-increase. The five US states with the highest 90-day costs were Alaska (+$14,751), Maryland (+$13,343), New York (+$7,428), Nevada (+$6,775), and California (+$6,731). Conclusion. Under the proposed DRG-based bundled payment methodology, surgeons would be reimbursed the same amount of money for revision TJAs, regardless of the indication (periprosthetic fracture, prosthetic joint infection, mechanical loosening) and/or patient complexity. Cite this article: Bone Joint J 2020;102-B(7):959–964


The Bone & Joint Journal
Vol. 105-B, Issue 12 | Pages 1294 - 1302
1 Dec 2023
Knoll L Steppacher SD Furrer H Thurnheer-Zürcher MC Renz N

Aims

A higher failure rate has been reported in haematogenous periprosthetic joint infection (PJI) compared to non-haematogenous PJI. The reason for this difference is unknown. We investigated the outcome of haematogenous and non-haematogenous PJI to analyze the risk factors for failure in both groups of patients.

Methods

Episodes of knee or hip PJI (defined by the European Bone and Joint Infection Society criteria) treated at our institution between January 2015 and October 2020 were included in a retrospective PJI cohort. Episodes with a follow-up of > one year were stratified by route of infection into haematogenous and non-haematogenous PJI. Probability of failure-free survival was estimated using the Kaplan-Meier method, and compared between groups using log-rank test. Univariate and multivariate analysis was applied to assess risk factors for failure.


The Bone & Joint Journal
Vol. 101-B, Issue 6_Supple_B | Pages 116 - 122
1 Jun 2019
Whiteside LA Roy ME

Aims. The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. Patients and Methods. A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter. Results. Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased. Conclusion. The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116–122


Bone & Joint Research
Vol. 13, Issue 4 | Pages 149 - 156
4 Apr 2024
Rajamäki A Lehtovirta L Niemeläinen M Reito A Parkkinen J Peräniemi S Vepsäläinen J Eskelinen A

Aims

Metal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium.

Methods

Periprosthetic metal concentrations in the synovia and histopathological samples were analyzed from 230 patients from our institution from October 2016 to December 2019. An ordinal regression model was calculated to investigate the effect of the accumulated metals on the histopathological reaction of the synovia.