Background The transepicondylar axis is often used for positioning of the femoral component in knee replacement.
MethodsWe studied the reproducibility of the intra-operative palpation of the transepicondylar axis for rotational alignment of the femoral component in 20 total knee replacement (TKR) implantations with a non-image-based navigation system. 2 surgeons defined the transepicondylar axis 3 times each without changing the reference plane.Results The angle between the reference plane and the transepicondylar axis was measured by the navigation system. The mean intra-observer ranges of variation were 5° and 6° for both surgeons, with a maximum of 15°. The mean inter-observer range of variation was 9°, with a maximum of 15°. Variations occurred in either internal or external rotation. Intra-observer agreement was considered good for one surgeon and poor for the other. There was no agreement between the two observers.Interpretation To define the rotational alignment of the femoral component of a TKR according to the intra-operative palpation of the transepicondylar axis may not be as reproducible as expected. However, the exact effect of this variability on the outcome after TKR should be studied.
We studied a consecutive series of 40 patients presenting a septic knee arthritis, with a mean age of 49 +/- 20 (range 19-81) years. The aetiologies were: 18 postoperative arthritis, 12 haematogenous infections, 7 arthritis following aspiration or infiltration, and 3 articular wounds. The most common organisms were Staphylococcus aureus and epidermidis (23 cases). Surgical procedures consisted in 20 arthroscopic debridements, 6 open debridements, 14 synovectomies. According to Gächter's classification, there were 8 stage I, 18 stage II, 11 stage III and 3 stage IV cases. Fifteen patients had to be reoperated after the index procedure at our institution: one open debridement, six open synovectomies, one open arthrolysis, one arthrodesis and six total knee arthroplasties (TKA). Final examination was performed after 22 +/- 26 (range 12-96) months. All cases were considered free of infection. Good functional result was present by 19/33 cases (excluding arthrodesis and TKA). The delay between the onset of symptoms and surgery was the major prognostic factor of success (P=0.023). This delay was correlated with Gächter's staging of the intra-articular lesions. The diagnosis of septic knee arthritis must be suspected at the early stage of the disease, and diagnostic joint aspiration must be immediately performed when the diagnosis is suspected. We suggest that the treatment should be more aggressive than generally advocated. Needle aspiration should be only performed at the very early stages. Arthroscopic debridement should be the routine treatment. Synovectomy should be considered even as a primary procedure when significant synovial hypertrophy is present (Gächter stage III and IV) or when a more conservative treatment did not lead to a fast improvement.
One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6–20.7) and 32.3 (95% CI 27.3–38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58–5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.Electronic supplementary materialThe online version of this article (10.1007/s10654-018-0377-9) contains supplementary material, which is available to authorized users.
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