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PubMed2004

Infection after total knee arthroplasty.

The aim of our study was to determine the current incidence and outcome of infected total knee arthroplasty (TKA) in our unit comparing them with our earlier audit in 1986, which had revealed infection rates of 4.4% after 471 primary TKAs and 15% after 23 revision TKAs at a mean follow-up of 2.8 years. In the interim we introduced stringent antibiotic prophylaxis, and the routine use of occlusive clothing within vertical laminar flow theatres and 0.05% chlorhexidine lavage during arthroplasty surgery. We followed up 931 primary TKAs and 69 revision TKAs for a mean of 6.5 years (5 to 8). Patients were traced by postal questionnaire, telephone interview or examination of case notes of the deceased. Nine (1%) of the patients who underwent primary TKA, and four (5.8%) of those who underwent revision TKA developed deep infection. Two of nine patients (22.2%) who developed infection after primary TKA were successfully treated without further surgery. All four of the patients who had infection after revision TKA had a poor outcome with one amputation, one chronic discharging sinus and two arthrodeses. Patients who underwent an arthrodesis had comparable Oxford knee scores to those who underwent a two-stage revision. Although infection rates have declined with the introduction of prophylactic measures, and more patients are undergoing TKA, the outcome of infected TKA has improved very little.

Adult↗
PubMed2005

Incidence of infection with the use of non-irradiated morcellised allograft bone washed at the time of revision arthroplasty of the hip.

Implantation of allograft bone is an integral part of revision surgery of the hip. One major concern with its use is the risk of transmission of infective agents. There are a number of methods of processing allograft bone in order to reduce this risk. One method requires washing the tissue using pulsed irrigation immediately before implantation. We report the incidence of deep bacterial infection in 138 patients (144 revision hip arthroplasties) who had undergone implantation of allograft bone. The bone used was fresh-frozen, non-irradiated and pulse-washed with normal saline before implantation. The deep infection rate at a minimum follow-up of one year was 0.7%. This method of processing appears to be associated with a very low risk of allograft-related bacterial infection.

Adult↗
PubMed2005

Osteolysis in a surface-cemented, primary, modular Freeman-Samuelson total knee replacement.

We analysed at a mean follow-up of 7.25 years the clinical and radiological outcome of 117 patients (125 knees) who had undergone a primary, cemented, modular Freeman-Samuelson total knee replacement. While the tibial and femoral components were cemented, the patellar component was uncemented. A surface-cementing technique was used to secure the tibial components. A total of 82 knees was available for radiological assessment. Radiolucent lines were seen in 41 knees (50%) and osteolytic lesions were seen in 13 knees (16%). Asymptomatic, rotational loosening of the patellar implant was seen in four patients and osteolysis was more common in patients with a patellar resurfacing. Functional outcome scores were available for 41 patients (41 knees, 35%) and the mean Western Ontario McMasters Universities score was 77.5 (sd 19.5) and the cumulative survival was 93.4% at ten years with revision for aseptic loosening as an endpoint. Increased polyethylene wear from modular components, a rotationally-loose patella, and the surface-cementing technique may have contributed to the high rate of osteolysis seen in our study.

Aged↗
PubMed2005

Radionuclide imaging of the painful hip arthroplasty: positron-emission tomography versus triple-phase bone scanning.

Two major complications of hip replacement are loosening and infection. Reliable differentiation between these pathological processes is difficult since both may be accompanied by similar symptoms. Our aim was to assess the diagnostic ability of triple-phase bone scanning (TPBS) and positron-emission tomography (PET) to detect and differentiate these complications in patients with a hip arthroplasty. Both TPBS and PET were performed in 63 patients (92 prostheses). The radiotracer for PET imaging was (18)F-fluorodeoxyglucose (FDG). Image interpretation was performed according to qualitative and quantitative criteria although the final diagnosis was based upon either surgical findings or clinical follow-up. The sensitivity, specificity and accuracy of PET was 0.94, 0.95 and 0.95 respectively, compared with 0.68, 0.76 and 0.74 for TPBS. We found that an image interpretation based exclusively upon quantitative criteria was inappropriate because of its low selectivity. The histological examination indicated that increased periprosthetic uptake of FDG in patients with aseptic loosening was caused by wear-induced polyethylene particles and the subsequent growth of aggressive granulomatous tissue.

Adult↗
PubMed2006

Revision of failed total elbow arthroplasty with use of a linked implant.

We studied retrospectively the results of revision arthroplasty of the elbow using a linked Coonrad-Morrey implant in 23 patients (24 elbows) after a mean follow-up period of 55 months. According to the Mayo Elbow Performance Score, 19 elbows were satisfactory, nine were excellent and ten good. The median total score had improved from 35 points (20 to 75) before the primary arthroplasty to 85 points (40 to 100) at the latest follow-up. There was a marked relief of pain, but the range of movement showed no overall improvement. Two patients had a second revision because of infection and two for aseptic loosening. The estimated five-year survival rate of the prosthesis was 83.1% (95% confidence interval 61.1 to 93.3). Revision elbow arthroplasty using the Coonrad-Morrey implant provided satisfactory results but with complications occurring in 13 cases.

Adult↗
PubMed2006

A comparison of bilateral uncemented total knee arthroplasty: simultaneous or staged?

In a series of 1304 patients (1867 knees), the results of simultaneous and staged bilateral total knee arthroplasty were compared with each other and with unilateral total knee arthroplasty. The bilateral procedures had a significantly higher rate of complications than unilateral procedures, almost entirely because of thromboembolic problems. However, this did not correspond to an increase in mortality. If a bilateral procedure was indicated, then a simultaneous procedure had no increased risk over a staged procedure. There was no increase in cardiovascular complications, the rate of deep-vein thrombosis or pulmonary embolism or mortality. The rate of infection was lower with a bilateral procedure and the overall revision rate was less than 1% in all groups. The prosthesis functioned as well in all groups in the medium and longer term periods. We feel that simultaneous bilateral total knee arthroplasty is a safe and successful procedure when compared with a staged bilateral procedure. It also has the added benefit of single anaesthetic, reduced costs and decreased total recovery time when compared to a staged bilateral procedure. For these reasons it should be considered as an option in the presence of bilateral knee joint disease.

Aged↗
PubMed2006

The Oxford medial unicompartmental knee replacement using a minimally-invasive approach.

This prospective study describes the complications and survival of the first 688 Phase 3 Oxford medial unicompartmental knee replacements implanted using a minimally-invasive technique by two surgeons and followed up independently. None was lost to follow-up. We had carried out 132 of the procedures more than five years ago. The clinical assessment of 101 of these which were available for review at five years is also presented. Nine of the 688 knees were revised: four for infection, three for dislocation of the bearing and two for unexplained pain. A further seven knees (1%) required other procedures: four had a manipulation under anaesthesia, two an arthroscopy and one a debridement for superficial infection. The survival rate at seven years was 97.3% (95% confidence interval 5.3). At five years, 96% of the patients had a good or excellent American Knee Society score, the mean Oxford knee score was 39 and the mean flexion was 133 degrees. This study demonstrates that the minimally-invasive Oxford unicompartmental knee replacement is a reliable and effective procedure.

Adult↗
PubMed2006

Penile prosthetic surgery and its role in the treatment of end-stage erectile dysfunction - an update.

The treatment of erectile dysfunction has been revolutionised with the introduction of orally active phosphodiesterase inhibitors which are successful in 70-80% of men. However, there remain a group of men in whom conservative treatment fails and surgical insertion of a penile prosthesis is required. This type of surgery has in the past been associated with technical difficulties and a high complication rate. This has spurred numerous developments in prosthesis design and surgical technique with the field changing at a rapid pace. Perhaps the most significant is the use of antimicrobial coatings on prostheses that have been shown to reduce the infection rate significantly. This review highlights those developments reported in the last 5 years.

Erectile Dysfunction↗
PubMed2006

Re-admission rates within 28 days of total hip replacement.

INTRODUCTION: The aim of the study was to identify the reasons for the higher than expected emergency re-admission to hospital within 28 days of total hip replacement (THR) for Stepping Hill Hospital, Stockport. PATIENTS AND METHODS: Over a 42-month period, 65 (8.5%) of 769 patients were re-admitted within 28 days of discharge following primary THR. Case notes for 61 patients were available for retrospective review to assess premorbidity, initial postoperative complications and reason for re-admission. RESULTS: The main reasons for re-admission were complications related to the procedure. These included thrombo-embolic disease 2.5%, atraumatic dislocation 1.4%, wound complications 1.2% and swollen limb 1.8%. Other causes such as admission to another department for problems not related to THR accounted for 0.8%. CONCLUSIONS: Our findings are comparable with the published literature for early complications following THR. The three main reasons for re-admission were atraumatic dislocation, thrombo-embolic and wound complications such as superficial infection and haematoma are the commonest world-wide. The re-admission rate to hospital within the first 28 days following THR was a clinical indicator suggested by the UK Department of Health. It has subsequently been incorporated in a group of indicators used by the CASPE Healthcare Knowledge Systems (CHKS), a private healthcare consultancy and analysis company, for peer benchmarking. Our re-admission rates are inflated by admissions for non-THR-related reasons. The level of post-THR complications leading to re-admission were acceptable compared with the available published literature regarding 28-day re-admission. We anticipate that this study may act as a benchmark for other trusts.

Adult↗
PubMed1998

Periprosthesis sepsis: an undesirable complication of silicone gastric banding.

BACKGROUND: Gastric banding is a very satisfactory procedure for the treatment of morbid obesity. The significant incidence of skin suppuration in these patients makes the laparoscopic approach a suitable technique. Regardless of this, in some cases, suppuration can still rarely result. METHODS AND RESULTS: In four patients the authors observed diffusion of suppuration in both directions along the catheter which connects the port to the band, necessitating band removal and thus invalidating the procedure. CONCLUSIONS: Suppuration of port location is an undesirable complication that must be avoided because it may contaminate the entire device system. This complication must be carefully evaluated for a correct diagnosis and an eventual removal of the band.

Adult↗
PubMed1993

Localized osteomyelitis secondary to endodontic-implant pathosis. A case report.

This case report documents the placement of a single implant fixture in an incisor extraction socket, with the adjacent lateral incisor developing periapical pathosis within 2 weeks. This root-end inflammatory process proceeded to communicate with the surface of the implant fixture. Although endodontic therapy was performed within one week on the devitalized tooth, and extensive osteomyelitis developed around the implant. Three weeks after placement, the fixture had to be removed. The osteotomy site appeared to be healing uneventfully during the one month follow-up period. Seven possible causes for this occurrence are discussed.

Dental Implantation, Endosseous↗
PubMed1995

Antimicrobial susceptibility of periodontopathic bacteria associated with failing implants.

The aim of this study was to examine the subgingival microflora associated with failing implants, and to determine their susceptibility to commonly used antibiotics in periodontal therapy and dental practice. Thirteen partially edentulous patients with 19 failing implants were selected. Clinical examination included probing depth, attachment level, gingival index, plaque index, and radiographic analyses. Two subgingival plaque samples were taken from each failing implant and analyzed for microbial composition. Fusobacterium nucleatum, Porphyromonas gingivalis, and Prevotella intermedia were the prevalent cultivable microflora. Antimicrobial susceptibility of isolates was determined by the agar dilution technique. Antibacterial activity of penicillin G, amoxicillin, amoxicillin-clavulanate, and the combination amoxicillin-metronidazole was significantly higher than with other antibiotics tested. These data indicated that the commonly-used antibiotics were highly effective against bacteria isolated around failing implants, which would suggest the use of these antibiotics to control peri-implant infections.

Amoxicillin↗
PubMed1993

The value of aspiration of the hip joint before revision total hip arthroplasty.

The role of aspiration of the hip joint before revision of a total hip arthroplasty remains controversial. To address this issue, we reviewed the results of 270 consecutive hips in which aspiration had been attempted before revision procedures that were performed between 1980 and 1988. All hips had intraoperative findings and clinical follow-up of at least two years to confirm the presence or absence of infection. Only six (2 per cent) of the 270 hips were determined to be infected. Aspiration had been attempted in all six hips, but fluid could be obtained from only four. All six hips also had clinical or radiographic signs, or both, of infection, including increasing pain within three years after the arthroplasty (four hips), inability of the patient to attain pain-free status after the original procedure (four hips), radiographic findings compatible with infection (six hips), and a positive finding on culture of a specimen obtained from a previous aspiration (two hips). Because of these factors, aspiration was attempted a second time in four of the six hips and a third time in three of the four. The four hips from which fluid could be obtained had a total of ten successful aspirations; the cultures of specimens obtained from six of these procedures were positive and those from four were negative. The appearance of the capsular tissue at the time of the operation suggested infection in five of the six infected hips. Histological sections were positive for inflammation in all six: there was acute inflammation only in one, chronic inflammation only in two, and acute and chronic inflammation in three. No organisms were seen on gram stains of specimens from any of the six infected hips. Of the 254 hips that did not have an infection and had been aspirated successfully, thirty-two (13 per cent) had a false-positive result on culture of a specimen of the aspiration fluid. Only two (6 per cent) of the thirty-four hips that had a positive result on culture of fluid from the initial aspiration had a true-positive result. No hip had a true-positive result on culture of fluid that had been aspirated preoperatively without also having clinical and radiographic evidence of infection. On the basis of these findings, we recommend that aspiration be performed in selected patients rather than routinely. It also should be performed only if a detailed clinical history suggests infection or if radiographs demonstrate focal lysis, aggressive non-focal lysis, or periostitis.

Aged↗
PubMed1994

The use of porous prostheses in delayed reconstruction of total hip replacements that have failed because of infection.

Between March 1984 and March 1989, thirty-four patients who had an infection at the site of a cemented total hip prosthesis were managed with resection arthroplasty and delayed implantation of a porous total hip prosthesis without cement. The interval from the time of the resection arthroplasty to the implantation of another prosthesis averaged eight months (range, three to nineteen months). At an average of forty-seven months (range, twenty-four to seventy-two months) after the reimplantation, six patients (18 per cent) had recurrence of the infection. Patients who had rheumatoid arthritis were at significantly higher risk for the development of a recurrent infection (p < 0.01). Of the twenty-eight patients who did not have a recurrent infection, six had definite radiographic evidence of loosening of the femoral component at the latest follow-up evaluation. For twenty-five of the twenty-eight patients, sufficient data were available for calculation of the Mayo Clinic hip score; only fourteen (56 per cent) of these patients had a satisfactory functional outcome. The high (68 per cent) rate of complications and the long-term durability of the prosthesis in these patients remain a concern. The fact that 18 per cent of the patients had a recurrent infection suggests that avoidance of the use of bone cement does not improve the rate of resolution of infection after a delayed revision operation in patients who have an infection following a total hip arthroplasty.

Adult↗
PubMed1994

Intramedullary arthrodesis of the knee after failed total knee arthroplasty.

Eighteen patients (eighteen knees) were managed with an intramedullary arthrodesis after a failed total knee arthroplasty. Twelve knees had had a revision total knee arthroplasty and six, a primary total knee arthroplasty. Three knees had had failure of a hinged prosthesis. In eleven knees, the arthroplasty had failed because of infection. Nine patients had had previous attempts at arthrodesis with external fixation. The average duration of the operation was six hours, and the average blood replacement was 2975 milliliters. A vascularized fibular pedicle graft was used in four patients. At a mean of thirty-seven months after the arthrodesis, sixteen of the eighteen patients had a complete radiographic union. The mean time to union was 5.5 months. Although a high rate of union was achieved in these patients, complications occurred in ten of the eighteen knees and this must be considered. Intramedullary arthrodesis is a successful method of salvage for a failed total knee arthroplasty or one complicated by infection that is not amenable to revision, but it is technically demanding and has frequent complications.

Adult↗
PubMed1995

Hip arthroplasty in hemophilic arthropathy.

As hemophilic arthropathy infrequently affects the hip joint, we performed a multicenter retrospective study to determine the results of hip arthroplasty in hemophilic patients. Thirty-four hip arthroplasties were performed in twenty-seven male patients at four major hemophilia centers from October 1972 through September 1990. Twenty-six patients had classic hemophilia and one had factor-IX deficiency. The mean age of the patients at the time of the operation was thirty-eight years (range, fifteen to seventy-three years). The mean duration of follow-up was eight years, with a minimum of two years for all patients who were still alive at the time of this review. Four patients were seropositive for the human immunodeficiency virus at the time of the operation, and sixteen patients were seropositive at the time of the most recent follow-up examination. Nine patients (33 per cent) died before the time of this review; seven had been seropositive for the human immunodeficiency virus. There were twenty-six total hip arthroplasties performed with cement, six total hip arthroplasties performed without cement, one total hip arthroplasty in which the femoral component was inserted with cement and the acetabular component was inserted without it (so-called hybrid arthroplasty), and one bipolar arthroplasty performed with cement. There were no early infections after these thirty-four primary arthroplasties. There were three late infections around prostheses inserted with cement, and all led to a resection arthroplasty. Six (21 per cent) of the twenty-eight cemented femoral components and six (23 per cent) of the twenty-six cemented acetabular components were revised because of aseptic loosening.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed1995

The role of intraoperative frozen sections in revision total joint arthroplasty.

We performed a retrospective analysis of thirty-three consecutive total hip and knee (twenty-three hip and ten knee) revision arthroplasties during which intraoperative frozen sections were analyzed. Data for the study were collected by means of a review of the charts, radiographic analysis, and evaluation of both frozen and permanent histological sections. The frozen sections, of periprosthetic tissue at the bone-cement interface or the pseudocapsule, were considered positive for active infection if there were more than five polymorphonuclear leukocytes per high-power field in at least five distinct microscopic fields. All patients were available for follow-up, at an average of thirty-six months (range, seventeen to seventy-nine months) after the initial revision operation. The frozen sections from ten patients were positive for infection, and those from twenty-three patients were negative. Comparison of the results of the analyses of the frozen sections (both positive and negative) with those of the analyses of the permanent histological sections of similar tissue showed a correlation of 100 per cent (sensitivity, 1.00; specificity, 1.00; and accuracy, 1.00). Nine patients had positive intraoperative cultures, and all of them had positive frozen sections (sensitivity, 1.00). Of the twenty-four patients who had negative intraoperative cultures, twenty-three had negative frozen sections (specificity, 0.96). Of the nine patients who had positive intraoperative cultures, only two were found to have infection on intraoperative gram-staining. The surgeon's operative assessment regarding the presence of infection, compared with the final pathological diagnosis, demonstrated a sensitivity of 0.70, a specificity of 0.87, and an accuracy of 0.82. All ten patients who had positive frozen sections were managed with excision arthroplasty; six of them subsequently had reimplantation, and the excision was the definitive procedure in the remaining four. One patient who had had a delayed reimplantation had a secondary skin slough and eventually was managed with an arthrodesis of the knee. In the group that had negative frozen sections, eighteen patients had a primary exchange revision arthroplasty and five had a delayed reimplantation. At the time of follow-up, one patient who had had a delayed reimplantation had radiographic loosening of the femoral component and was asymptomatic. One patient who had had a primary exchange arthroplasty was managed with a second revision because of aseptic loosening. There was no clinical recurrence of infection in any patient. The data indicate that analysis of frozen sections of periprosthetic tissue is a reliable predictor of the presence of active infection during revision joint arthroplasty. We recommend its use to differentiate aseptic from septic loosening.

Adult↗