To compare complications, survivorship and results in 2 groups of Furlong-HAP Active, one with ceramic-ceramic and the other with metal-XLPE friction pair

Prospective, non-randomized, comparison of 2 series of JRI uncemented prosthesis, implanted with identical protocol by 1 surgeon in 1 hospital from 2006 to 2014. Friction pair was ceramic (Biolox Forte or Delta) in 35 patients of 53.7+/−10.6 years (25–69) (21 males, 60%), and CrCo-XLPE in 65 cases of 69.0+/−8.9 years (42–81) (36 males, 55%); there were significant differences in age (p<0.00001) but not in sex (p=0.6565).

Head diameter: Ce-Ce with 19 of 28mm, 9 of 32 and 7 of 36mm; Me-PE with 63 of 28mm, 1 of 32 and 1 of 36. Follow-up averaged 10.5+/−3.1 years (1–15) in ceramic and 9.8+/−3.8 years (2–15) in XLPE group. Pearson, Fisher, Kolmogorov-Smirnov, Student, Mann-Whitney, calculated with the informatic tools Microsoft Excel 2007 and https://www.socscistatistics.com/tests/.

Complications in ceramic joints: 2 late infections (Fisher exact test=0.6101) (1 DAIR, 1 one-stage exchange); 1 dislocation (Fisher exact test=0.2549) (closed reduction); 1 Vancouver C fracture (ORIF) (Fisher exact test=0.6548). Complications in Me-XLPE joints: 2 late infections (Fisher=0.6101) (1 DAIR, 1 two-stage exchange); 7 dislocations (Fisher=0.2549) (2 early, open reduction) (5 late: 3 closed reduction, 1 cup revision, 1 constrained cup); 4 Vancouver B fractures (Fisher=0.6548) (2 intraoperative, cerclages; 2 late, exchange).

Final follow-up: Harris Hip Score averaged 93.2+/−13.7 (23–100) in ceramic and 94.3+/−8.7 (65–100) in XLPE joints (p=0.64552).

Wear: 0.06+/−0.38mm (0–1.5) in ceramic and 0.16+/−0.5mm (0–2) in Me-PE THAs (p=0.30302).

Osteolysis in Charnley-De Lee zones: 8 zones (6 patients) (17%) in ceramic cups, 25 zones (15 patients) (23%) in XLPE cups (p=0.980127).

Survivorship without any surgery or closed reduction after 15 years: 91.0% in ceramic joints, 83.8% in Me-XLPE joints.

Survivorship without component exchange after 15 years: 93.9% in ceramic joints, 93.6% in Me-XLPE joints.

At least after 10 years follow-up of Furlong-HAP Active, metal-XLPE and ceramic-ceramic joints present no significant differences in complications, clinical score, wear, acetabular osteolysis, or survivorship without component exchange. On the contrary, survivorship without any surgery or closed reduction is different because of the high rate of dislocation in 28mm metal-poly joints.

Aims

We previously reported the long-term results of the cementless Duraloc-Profile total hip arthroplasty (THA) system in a 12- to 15-year follow-up study. In this paper, we provide an update on the clinical and radiological results of a previously reported cohort of patients at 23 to 26 years´ follow-up.

We assessed the clinical and radiological outcome of a single uncemented total hip replacement (THR) after twenty years, analysing polyethylene wear and osteolysis.

82 hips implanted between 1992 and 1995 were prospectively evaluated. Mean follow-up was 20.6 years (18–23). A hemispherical porous-coated cup matched to a proximally hydroxyapatite-coated anatomic stem. A 28mm PE liner, sterilised by gamma irradiation in air, was used in all hips. Radiological position, eventual loosening and osteolysis were recorded over time. Penetration of the head into the liner was measured by the Roentgen Monographic Analysis (ROMAN) Tool at 6 weeks, 6 months, one year and yearly thereafter.

Six cups were revised due to wear and four cups because of late dislocation. All stems showed osseointegration and all cups appeared radiographically well-fixed. Six unrevised hips showed osteolysis on the acetabular side and two hips on the proximal femur. Creep at one year was 0.30±0.23 mm. Mean total femoral head penetration was 1.23mm at ten years, 1.52mm at 15 years and 1.92mm at 23 years. Overall mean wear was 0.12±0.1 mm/year and 0.09±0.06 mm/year after the creep period. Mean wear was 0.08±0.06 mm/year in hips without osteolysis and 0.14±0.03 mm/year in hips revised or hips with osteolysis (p<0.001).

Although continued durable fixation can be observed with porous-coated cups and proximally hydroxyapatite-coated anatomic stems, true wear continues to increase at a constant level over time. PE wear remains as the main reason for osteolysis and revision surgery in uncemented THR after twenty years.

To analyze the evolution of “Tsukayama type IV” infections (unexpected positive intraoperative cultures in hip arthroplasty -THA- exchange because of supposedly mechanical failure) treated with an extended protocol of combined oral antibiotics.

Prospective cohort: 14 patients, 66.9+/−10.9 years (40–85), 11 males (78.6%). Eleven suffered isolated cup exchange: 6/14 first cup-exchange, 4/14 second (one with a 1st Slooff impaction-grafting reconstruction and 2 with a 2nd Slooff reconstruction), 1/14 third cup-exchange. Two were operated of isolated stem exchange. One patient received a complete exchange. Cultures identified 10 epidermidis (5 methicillin-resistant -MR-), 4 aureus (3 MR), 1 Propionibacterium, 1 Enterococcus, 1 Escherichia, 1 Streptococcus, 1 Corynebacterium, and 1 Ruminococcus. Patients received 2 oral combined intracellular and biofilm-effective antibiotics for 6 months: ciprofloxacin (8 patients), rifampin (6), amoxicillin-clavulanic (3), levofloxacin (2), clindamycin (3), trimethoprim-sulfamethoxazole (2), fosfomicin (2). Follow-up: 4.5+/−4.3 years (1–14). Healing: absence of clinical, serological and radiographic signs of infection along all followup.

Infection reappeared in 1/14 patients (7.1%) with pain, distance limitation and elevated ESR&CRP; patient rejected surgery and was treated with a 2nd cycle of oral antibiotics, disappearing symptoms and serological abnormality along the following 7 years. The other 13 cases maintained normal ESR&CRP along follow-up. At the end of follow-up, 4/14 hips remain asymptomatic and with no limitation of function, 11/14 present no pain, 10/14 walk over 1Km without support, 1/11 uses a cane, 1/14 two crutches, and 2/14 a walker.

In conclusión, oral combined antibiotics may be a useful alternative therapy for Tsukayama type IV hip arthroplasty infections.

Summary Statement

Combination of antibiotics with N-acetylcisteine and sub-MIC concentration of erythromycin was evaluated in two collection and 16 clinical strains of staphylococci isolated from PJI. The results were strain-dependent, so it evidences the necessity of perform individual studies of biofilm susceptibility.

INTRODUCTION

Prosthetic joint related-infections (PJRI) are severe complications in orthopaedic surgery. Staphylococcus aureus and Staphylococcus epidermidis are the most commonly isolated pathogens from implants (1). The variable antimicrobial susceptibility found in these microorganisms, makes it necessary to perform individual susceptibility studies in order to select the best antibiotic combination for clinical management (2).

Introduction: Deep infection continues to be the first most important early complication in knee arthroplasty. It is usual to apply standard prophylaxis to all patients, but it is not usual to use special measures in those of them who present a higher risk. Moreover, sometimes these patients are even not identified.

Purpose: To analyse statistically significant risk factors for deep infection in patients with a knee arthroplasty.

Patients and Methods:

Design: Case-control study.

Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections.

Case series: 32 consecutive patients with a deeply infected knee arthroplasty operated in the same Department of a University General Hospital.

Control series: 100 randomly selected patients, operated in the same hospital and period of time, with no deep infection in their knee arthroplasty along follow-up.

Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones.

Results: The following risk factors were significantly more frequent (p< 0.05) in the patients with an infected knee arthroplasty:

Preoperative conditions: previous surgery in the same knee (25% vs 9%), chronic therapy with glucocorticoids (19% vs 4%), immunosuppressive treatments (16% vs 3%), and non-rheumatoid inflammatory arthritis (13% vs 0%). Patients in this case-control did not present a significant difference in the prevalence of rheumatoid arthritis, diabetes, obesity (BMI> 30), chronic liver diseases, or alcohol addiction.

Conclusion: To identify significative risk factors for deep infection in knee arthroplasty is important:

to control and minimize these risk factors when present

Introduction: Deep infection continues to be the second most important early complication in hip arthroplasty. It is usual to apply standard prophylaxis to all patients, but it is not usual to use special measures in those of them who present a higher risk. Moreover, sometimes these patients are even not identified.

Purpose: To analyse statistically significant risk factors for deep infection in patients with a hip arthroplasty

Patients and Methods:

Design: Case-control study.

Observational and retrospective comparison of incidence or prevalence of all risk factors described in the literature. These factors have been classified according to the period of risk in: epidemiologic; pre, intra and postoperative; and distant infections.

Case series: 47 consecutive patients with a deeply infected hip arthroplasty operated in the same Department of a University General Hospital.

Control series: 200 randomly selected patients, operated in the same hospital and period of time, with no deep infection in their hip arthroplasty along follow-up.

Pearson was used for comparison of qualitative variables and ANOVA for quantitative ones.

Results: The following risk factors were significantly more frequent (p< 0.05) in the patients with an infected hip arthroplasty:

Epidemiologic characteristics: female gender, post-traumatic osteoarthritis (17% vs 3%). On the contrary, primary osteoarthritis is a “protective” factor.

Conclusion: To identify significative risk factors for deep infection in hip arthroplasty is important:

to control and minimize these risk factors when present

Introduction: Papers about high-virulence infections are not usual, results contradictory, and orthopaedic outcomes not described.

Purpose: to compare infectious and orthopaedic results after late arthroplasty infections by single vs. polymicrobial isolates, low vs. high-virulence, and Gram-positive vs. Gram-negative organisms, when treated by exchange surgery plus long cycles of combined oral antibiotics.

Patients and Methods: A late arthroplasty infection was diagnosed in 68 consecutive patients (48 female) of 72.2(+/−10.2) years (37 hips/31 knees).

Cultures were polymicrobial in 22 cases and by Gram-positive in 55 (80.9%). Highly-resistant organisms: methicillin-resistant Staphylococcus (36 patients) and ESBL-producing Enterobacteriaceae (2 patients). “Problematic-treatment”: Enterococcus (6 patients), Pseudomonas (3 patients), non-fermenting Gram-negative (2), moulds (1).

Oral antibiotic selection: according to bacterial sensitivity, biofilm and intracellular effectiveness. Protocolized surgery: two-stage exchange. Average follow-up: 4.7+/−2.7 years (1–11).

Healing of infection is diagnosed if absence of clinical, serological and radiological signs of infection during the whole follow-up. Orthopaedic outcome is evaluated by HHS for hips and by KSCRS for knees.

Results: Surgery was not possible in 7 infections (rejected by patients), and reimplantation in 17 additional cases (patients died shortly after first surgery, rejected 2nd surgery, or was contraindicated because of medical reasons).

Healing of infection: 59/68 patients (86.8%), 32/37 hips (86.5%) and 27/31 knees (87.1%). Infection not healed: 7/68 cases (10.3%) (4/37 hips, 3/31 knees) (5 by highly-resistant and 1 by “problematic-treatment” bacteria). There are no differences between hips and knees (p=0.55).

Orthopaedic Results: HHS averages 80.5+/−16.2 (81+/−16 in healed infection, 56+/−23.5 in persistent infection). KSCRS averages 77.2/58.1 +/− 19.8/24.5 in healed infections, 32.6/0+/−25.8/0 in persistent infections. Infective and orthopaedic results present a strong statistical correlation in hips (p=0.016) and knees (p=0.0001).

Statistically significant differences are not found when comparing subgroups according to Gram stain (p=0.43), multiple vs single bacteria (p=0.47 infective, p=0.71 orthopaedic), highly-resistant bacteria (p=0.2 infective, p=0.1/0.5 orthopaedic), or “problematic-treatment” (p=0.68).

Conclusions:

A strong statistical correlation appears between infective and orthopedic results after late arthroplasty infections.

Introduction and Objectives: The medical literature describes asymptomatic urinary tract infections (UTI) in up to 30% of postmenopausal women. Our aim was to analyze the prevalence of asymptomatic UTI in patients waiting to undergo programmed hip/knee arthroplasty and also the risk of dissemination of the infection through the blood stream.

Materials and Methods: We included 200 patients that had undergone hip/knee arthroplasties in our study (15.1.07–22.10.07). 69.97+/−10.28 years of age, 130 women/70 men. Urine and sediment analysis on entry (12 hours before surgery). Abnormal values: density< 1.006/> 1.030; pH< 4.6/> 7.0; leucocytes and/or positive nitrites; sediment with bacteriuria, piuria and/or > 5 leucocytes/field. If the urine or sediment analysis gave abnormal values: Preoperative quantitative urine culture. If < 10.000 CFUs/ml, no UTI; > 10.000 but < 100.000 urine culture is repeated; > 100.000 CFUs, diagnosis of UTI, specific antibiotics orally for 7 days during the postoperative period. None of the patients underwent urethra catheterization. All received cefazoline 1g i.v/8 hours for 48 hours postoperatively.

Results: Loss to follow-up: 0 patients. If the urine or sediment analysis gave abnormal values: 82/200 patients of 72.59+/−7.32 years of age, 72 women/10 men. In 11/82 patients: no valid uroculture. In 8/82 patients (8/200, 4% of the total series): Pathological urine culture, 4 E. coli, 1 P. aeruginosa, 1 P. putida, 1 K. oxytoca, 1 K. pneumoniae. Treatment: quinolones/amoxicillin-clavulanic acid (not carried out in 3 cases). Up to the now there are no signs of infection in the arthroplasties.

Discussion and Conclusions:

Patients undergoing programmed hip/knee arthroplasties frequently have abnormal preoperative urine analysis.

Introduction: There are descriptions in the medical literature of asymptomatic bacteriurias in 30% of post-menopausal women.

Purpose: To analyze the prevalence of asymptomatic bacteriuria and the risk of blood-route dissemination in patients undergoing elective hip arthroplasty.

Patients and Methods: All asymptomatic patients undergoing surgical hip arthroplasty between January 15, 2007 and March 30, 2007 were included. There was a total of 45 patients of 65.9 +/−12.9 (range: 33–85) years of age, out of which 23 (51.1%) were male. A urine test was administered on admission (12 hours before surgery). Normal analysis: density< 1.006/> 1.030; pH< 4.6/> 7.0; leucocytes and/or positive nitrites; sediment with bacteriuria, piouria and/or > 5 leucocytes/field. If the urine analysis was abnormal, a preoperative quantitative uroculture was carried out. If < 10000 CFUs/ml, no UTI (urinary tract infection); if > 10000 but < 100000, a new urine culture was performed; if > 100000 CFUs, diagnosis of UTI, specific oral antibiotics were administered for 7 days postoperatively. None of the patients underwent urethra catheterization. All received cefazoline 1g i.v/8 hours for 48 hours postoperatively.

Results: Loss to follow-up: 0 patients. Normal analysis: 12/45(26.7%) patients of 73.8+/−8.5 (55–85) years of age, 12 females (100.0%). In 1 of these 12 patients (8.3%) (1/45 or 2.2% of the total series) the urine culture was positive for Pseudomona aeruginosa. Up to the current time none of these 45 patients has developed signs of infection in their arthroplasty.

Conclusions:

(1) Women undergoing elective hip arthroplasty frequently have abnormal preoperative urine analysis.

We reviewed 111 hemispherical Duraloc series-500 acetabular components with a minimum follow-up of 12 years. The mean clinical and radiological follow-up was 13.4 years (12 to 15). A Profile hydroxyapatite-coated anatomical femoral component was used in each case. Six patients had a late dislocation, for whom the polyethylene liner was exchanged. Each acetabular component was well fixed and all femoral components showed signs of bone ingrowth. The mean rate of femoral head penetration was 0.10 mm/year (0.021 to 0.481). The probability of not developing femoral cortical hypertrophy and proximal osteopenia by 12 years was 80.2% (95% confidence interval, 72.7 to 87.6) and 77.5% (95% confidence interval, 69.7 to 85.2), respectively. Despite these good clinical results, further follow-up is needed to determine whether these prostheses will loosen with time.

Objective: to measure cartilage and bone acetabular erosion in patients treated with a bipolar hip hemiarthroplasty because of a femoral neck fracture.

Material and methods:

- 34 patients, 31 female. average age 72.9 +/− 7.1 years (56–90)

- Level of activity previous to fracture: 82.4% level III, 14.6% level II

- Displaced (Garden III and IV) fracture of femoral neck excluding pathologic fractures

- Hip hemiartrhoplasty with a JRI Furlong bipolar head (22.25 mm inner head), 30 patients with a Furlong HAP-coated uncemented stem and 4 patients with an auto-blocking-type Surgival cemented stem

- Follow-up: minimum 2 years, average 2.9 years (2–5)

- Clinical evaluation: Merle-DAubigne-Postel six-point scale for pain and for function

- Radiological evaluation: measure of joint line width at superior-lateral quadrant (weight bearing area), perpendicular distance from prosthesis head to Kohler line

- Statistical analysis: Kolmogorov-Smirnov, ANOVA, Bonferroni, Pearson, and Spearman tests

Results – Pain: average score 4.5 +/− 1.3 after 1 year, 4.7 +/− 1.3 after 2 years, 4.6 +/− 1.4 after 3 years

- Function: average score 4.7 +/− 1.1 after 1 year, 4.7 +/− 1.4 after 2 years, 4.8 +/− 1.3 after 3 years

- Radiological joint line: disappeared in 13 patients (38.2%) after 1 year, in 14 (41.2%) after 2 years, in 54.5% of patients after 3 years. Average joint line width in the other patients: 0.9 mm (0.6–1.3) immediately after surgery, 0.6 mm (0.4–0.8) after 1 year, 0.5 mm (0.3–0.7) after 2 years, 0.5 mm (0.2–0.7) after 3 years (p< 0.05)

- Distance from head to Kohler line: 5.7 +/− 3.8 mm (4.6–6.8) immediately after surgery, 4.6 +/− 3.7 mm (3.6–5.6) after 1 year, 4.3 +/− 2.9 mm (3.3–5.3) after 2 years, 4.0 +/− 3.3 mm (2.5–5.5) after 3 years (p< 0.05). There were 2 cases of acetabular protrusion.

Conclusions 1. Bipolar heads in hemiarthroplasty do not avoid acetabular erosion. 2. The radiological progressive erosion does not correlate with clinical worsening of the patients.

Purpose: To analyse prolonged combinations of oral intracellular-effective antibiotics plus two-stage exchange surgery for treatment of chronic THA and TKA infections.

Materials and Methods: Definition of infected case: more than 3 months from surgery; multiple positive intraoperative cultures and/or active fistulae.

33 patients were treated from 1996 to 2002: 8 THA, 5 hip hemiarthroplasties, 20 TKA.

Bacteriology: 24 Staphylococci of which 16 were methycillin-resistant, 7 multi-resistant Gram-negative, 2 Cory-nebacteriae; 7 polymicrobian.

Antibiotic therapy: two simultaneous oral antibiotics, selected according to bacterial sensitivity and intracel-lular effectiveness (rifampin, ofloxacin, ciprofloxacin, levofloxacin, trimethoprim-sulfamethoxazole, fosfomicin, linezolid, doxiciclin), were used on an outpatient basis (between 1st and 2nd surgery, and after 2nd surgery until serological normalization). Patients received intravenous antibiotics and were in-hospital only for one week after surgery.

Surgery: two-stage exchange with 2nd stage delayed until clinical and serological normalization.

Healing of infection: absence of clinical, serological and radiological evidence of infection along all follow-up.

Prospective follow-up: 24-96 months.

Results: Healing of infection: 32/33 patients (97%).

Treatment failure: 1 patient (TKA) (3%).

THA: 8/8 infections healed: 1 Girdlestone patient (1st stage of exchange) rejected reimplantation; 7 two-stage exchange (good/excellent objective and subjective result).

Hip hemiarthroplasty: 5/5 infections healed: 3 Girdlestone (1st stage of exchange surgery, 2nd stage rejected because of hemiplegia or Alzheimer); 2 two-stage exchange (good/excellent objective and subjective result).

TKA: 19/20 infections healed: 3 resection-arthroplasty (1st stage of exchange surgery, 2nd stage rejected because of Buerger, cirrhosis or Alzheimer); 17 two-stage exchange (15 good/excellent objective and subjective results, 1 patient needed a debridement 2 months after 2nd surgery because of prolonged aseptic drainage and healed uneventfully, 1 failure described).

Conclusions: Prolonged combinations of oral intracellular-effective antibiotics associated with two-stages exchange surgery is a promising alternative for treating deep chronic THA and TKA infections. Longer follow-up and larger series are necessary.

Aims: internal fixation is not generally accepted as election treatment for displaced femoral neck fractures in patients older than 70. Results and risk factors are analysed in this later group of patients. Patients and Methods: 155 patients older than 70 with displaced femoral neck fractures were treated with closed reduction and parallel cannulated screws and prospectively followed for 2 years. Patients were allowed postoperative full weight bearing with aids. Quality of reduction and osteosynthesis were radiologically analysed. Results: 24 patients (15%) were lost. At the end of follow-up 52% of patients were asymptomatic, 13% had mild pain, 28% suffered a 2nd surgery (arthroplasty) and 7% were badly ill for aditional surgery. 57% presented uncomplicated consolidation, 28% non-union and 8% ischemic necrosis. Poor-quality reduction (p= 0.039) and poor-quality osteosynthesis (p=0.051) were significant risk factors for failure. A higher age (p=0.36), displacement (Eliason criteria) (p=0.26) and delay in surgery (p=0.53) were not significant risk factors. Conclusions: closed reduction and percutaneous fixation of displaced femoral neck fractures achieves good/fair results in only 65% of patients older than 70 years. Poor-quality reduction and osteosynthesis are risk factors for clinical and/or radiological failure.