The arthroscopic drainage, irrigation, and débridement of late, acute total hip arthroplasty infections: average 6-year follow-up

We present our experience with arthroscopy for the treatment of late, acute periprosthetic hip infections in 8 consecutive patients, treated from 1989 to 1994. After a hip aspiration confirmed the presence of bacterial infection, all patients underwent prompt arthroscopic treatment, which consisted of drainage, lavage, and debridement. Postoperatively, patients were given 2 to 6 weeks of intravenous antibiotics, followed by long-term oral antibiotic suppression. At a mean follow-up of 70 months (range, 29-104 months), no recurrence of infection occurred. No progressive radiographic loosening was noted. Based on this initial study, we believe that arthroscopic irrigation and debridement can benefit well-selected patients who suffer late, acute hip periprosthetic infections. Effective treatment requires early diagnosis, prompt arthroscopic debridement, well-fixed components, a sensitive microorganism, and patient tolerance to and compliance with the antibiotic therapy.     

Arthroscopic débridement for osteoarthritis of the knee

BACKGROUND: The role of arthroscopic débridement in the treatment of osteoarthritis of the knee remains to be defined, and few clinical and radiographic characteristics have been quantitatively associated with the outcome. The hypothesis of this study was that the outcome of arthroscopic débridement for osteoarthritis of the knee is associated with preoperative clinical and radiographic features and intraoperative characteristics and that there are subsets of patients who are more and less likely to respond favorably to the treatment. METHODS: We performed a cross-sectional study of a consecutive cohort of 122 patients who underwent arthroscopic débridement for the treatment of osteoarthritis of the knee that had been unresponsive to anti-inflammatory therapy. One hundred and ten patients were followed for a mean of thirty-four months. Pain was assessed with the pain domain of the Knee Society scoring system. Radiographs were scored with the Kellgren-Lawrence method, and limb alignment and the widths of the medial and lateral joint spaces were measured. The severity of cartilage lesions was scored intraoperatively with a modified Noyes grading system. Specific methods of data collection and analysis were incorporated to minimize bias. RESULTS: Fifty-two (90%) of fifty-eight knees with mild arthritis, normal alignment, and a joint space width of > or = 3 mm were improved after arthroscopic débridement. Conversely, only five (25%) of twenty knees with severe arthritis, limb malalignment, and a joint space width of < 2 mm had substantial relief of symptoms. Of seventy-two patients who had improvement, forty-four (61%) had it within six months after the arthroscopy. The severity of the lesion was highly predictive of the clinical outcome both in patients with mild arthritis and in those with severe arthritis. CONCLUSIONS: The severity of the arthritis, as assessed preoperatively with radiography and intraoperatively by rating the severity of cartilage lesions, influences the clinical outcome of arthroscopic débridement of an osteoarthritic knee. Knees with severe arthritis fare poorly, whereas those with mild arthritis fare well. We could not predict the outcome for knees with moderate arthritis. We believe that these observations are relevant for establishing indications for arthroscopy in patients with osteoarthritis of the knee and may be useful for designing studies with a more rigorous experimental design.     

Infected total hip arthroplasty after intravesical bacillus Calmette-Guérin therapy

An infected total hip arthroplasty remains one of the most challenging problems faced by orthopedic surgeons. We present the case of a 76-year-old man with an unusual infected total hip arthroplasty. Four years before presenting to our service, the patient was treated for vesical transitional cell carcinoma with intravesical administration of bacille Calmette-Guérin. The patient presented with groin pain, radiographic loosening of the hip implant, and elevated erythrocyte sedimentation rate and C-reactive protein. He underwent irrigation and debridement of the hip with removal of components. Cultures isolated bacille Calmette-Guérin necessitating treatment with antituberculosis chemotherapy. Bone cultures obtained under computed tomography guidance were negative, and reimplantation surgery was performed with a successful outcome. Pathway of infection spread, diagnosis, and treatment of this rare infection are discussed with review of the literature.     

Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies?

Purpose

Whilst patients undergoing total knee replacements generally have good relief of their symptoms, up to 20% complain of persisting pain. Revision rates have therefore been rising, particularly so for unexplained pain. We reviewed the causes of painful total knee replacements including extrinsic causes.

Methods

Forty-five consecutive patients referred to our department with painful total knee replacement were reviewed with our standard protocol, including history and examination, inflammatory markers and radiological studies including radiographs of the hip and knee and computed tomography scan of the knee joint.

Results

Of the 45 patients, 15 patients had degenerative hip and lumbar spine disease which resolved after injections of the relevant joints. Nine patients had unexplained pain.

Conclusions

Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.     

Wear in total knee arthroplasty—just a question of polyethylene?: Metal ion release in total knee arthroplasty

Purpose

Biological reactions against wear particles are a common cause for revision in total knee arthroplasty. To date, wear has mainly been attributed to polyethylene. However, the implants have large metallic surfaces that also could potentially lead to metal wear products (metal ions and debris). The aim of this study was to determine the local release of cobalt, chromium, molybdenum and titanium in total knee arthroplasty during a standard knee wear test.

Methods

Four moderately conforming fixed-bearing implants were subjected to physiological loadings and motions for 5×10⁶ walking cycles in a knee wear simulator. Polyethylene wear was determined gravimetrically and the release of metallic wear products was measured using high resolution-inductively coupled plasma-mass spectrometry.

Results

A polyethylene wear rate of 7.28 ± 0.27 mg/10⁶ cycles was determined and the cumulative mass of released metals measured 1.63 ± 0.28 mg for cobalt, 0.47 ± 0.06 mg for chromium, 0.42 ± 0.06 mg for molybdenum and 1.28 ± 0.14 mg for titanium.

Conclusion

For other metallic implants such as metal-on-metal total hip arthroplasty, the metal wear products can interact with the immune system, potentially leading to immunotoxic effects. In this study about 12 % by weight of the wear products were metallic, and these particles and ions may become clinically relevant for patients sensitive to these materials in particular. Non-metallic materials (e.g. ceramics or suitable coatings) may be considered for an alternative treatment for those patients.     

Long-term survival and radiological results of the Duracon™ total knee arthroplasty

Purpose

The aim of this study was to analyse the long-term (>ten years) survival rate and radiological results of the Duracon TKA.

Methods

Between 1992 and 1999 159 Duracon TKA were implanted at our institution. A Kaplan-Meier survival analysis for the endpoints exchange, addition or removal of any component for any reason, revision due to aseptic loosening and mechanical failure was performed. Radiological long-term (>ten years) follow-up (FU) analysis was performed according to the Knee Society Radiographic Evaluation and Scoring System.

Results

Mean age at surgery was 74.3 years, 28 % were male, and 89 % had primary osteoarthritis as diagnosis. Mean FU for survival analysis was 10.9 years (SD 4.2). A total of 58 % of the patients died during follow-up. Three patients (2.1 %) were lost to follow-up and five TKA (3.1 %) were revised. After ten years the mean survival was 97.7 %, 99.4 % and 98.3 % for the aforementioned endpoints, respectively. Mean radiological FU was 11.8 years (SD 2.3). We found no significant change in alignment of the components or axis over time. Progressive radiolucencies were found in nine TKA (17 %), mainly around the tibial component (95 %).

Conclusion

The Duracon TKA showed excellent long-term survival comparable to data from national registers and to other successful designs. Radiological changes found on plain radiographs were scarce after almost 12 years of radiological follow-up indicating good implant stability.     

Infected total hip arthroplasty – the value of intraoperative histology

Intraoperative histology showed a sensitivity of 100% and a specificity of 98%. These results were better than those observed for the other tests evaluated. Our data provide evidence that intraoperative histology is useful tool in the diagnosis of infected total hip arthroplasty.     

Continuous femoral nerve block after total knee arthroplasty?

Background: A continuous femoral nerve block is frequently used as an adjunct therapy after total knee arthroplasty (TKA). However, there is still debate on its benefits.
Methods: In this prospective, randomized study, patients received a basic analgesic regimen of paracetamol and dicloflenac for the first 48 h postoperatively. In addition, the study group received a continuous femoral nerve block. A morphine patient-controlled analgesia pump was also available as a rescue analgesic to all the patients. Patients' numeric rating scores for pain, the amount of morphine consumed and its side effects during the first 48 h were recorded. Knee flexion angles achieved during the first week were registered. Three months postoperatively, patients completed Western Ontario and McMaster Universities Osteoarthritis Index and Knee Society Score.
Results: The study group ( n =27) had less pain ( P =0.0016) during the first 48 h, was more satisfied with the analgesia ( P <0.001) and used less morphine ( P =0.007) compared with the control group ( n =26). Fewer patients were nauseated, vomited or were drowsy in the study group ( P =0.001). Also, the study group achieved better knee flexion in the first 6 days after surgery ( P =0.001), with more patients reaching 90° flexion than the control group. However, after 3 months, there were no significant functional differences between the groups.
Conclusion: A continuous femoral nerve block leads to better analgesia, less morphine consumption and less morphine-related side effects after TKA. Early functional recovery is improved, resulting in more patients reaching 90° knee flexion after 6 days. However, after 3 months, no significant functional benefits were found.     

How to reduce osteopenia in total knee arthroplasty?

European Journal of Orthopaedic Surgery & Traumatology - Osteopenia of the front half of the distal femur is a well-known problem after total knee arthroplasty (TKA) with secondary issues after...     

Patella in total knee arthroplasty: to resurface or not to��a cohort study of staged bilateral total knee arthroplasty

The aim of this study was to assess medium term results of patellar resurfacing in total knee arthroplasty, specifically looking at anterior knee pain, patellofemoral function and need for reoperation. A prospective cohort study was conducted with patients undergoing staged bilateral knee arthroplasty with the patella being resurfaced only on one side. This was due to change in the clinical practice of the senior author. Sixty patients were reviewed clinically and radiologically on a regular basis. The surgery was either performed or supervised by the senior author in all cases. All patients received the cemented press-fit condylar© prosthesis. The Knee Society clinical rating system was used. Scores were recorded pre-operatively and post-operatively at three months, one year, two years and three yearly thereafter. The mean age of patients in the study group was 75 years (range: 62–89 years). There were 42 women and 18 men in the study. The mean duration of follow-up was 4.5 years (range: 2–12 years). There was no significant difference in the pre-operative scores in both groups. There were significantly better scores (p < 0.05) on the resurfaced side as compared to the non-resurfaced side at final follow-up. No revision was carried out for patellofemoral complications on the resurfaced side. Four patients required revision in the form of patellar resurfacing on the non-resurfaced side for persistent anterior knee pain. Patellar resurfacing is recommended in total knee arthroplasty for better functional outcome with regards to anterior knee pain and patellofemoral function.     

Do patients need to earn total knee arthroplasty?

Traditional orthopaedic thinking dictates that performing total knee arthroplasty (TKA) in patients with relatively early stages of osteoarthritis (OA) will lead to a poor outcome. Our goal was to test this perception, using radiologic parameters as a marker of the degree of OA. Our study involved 130 consecutive patients who underwent TKA for OA. The radiographs of each patient were graded according to the Ahlback classification. Outcome was measured prospectively using the Oxford Knee Score (OKS), which was recorded both preoperatively and 1 year after surgery. The degree of radiologic OA changes preoperatively was not found to influence the outcome of surgery at 1 year, with all patient groups improving to a similar extent. In addition, as has been seen in previous studies, no correlation was found between symptoms of OA and radiologic appearances. The results of this study would support a re-evaluation of traditional orthopaedic practice. This conclusion coincides with other recent work that suggests that TKA is underused and is performed too late in the natural history of OA of the knee.