Background and purpose For prosthetic joint-associated infection (PJI), a regimen of debridement, antibiotics, irrigation, and retention of the prosthesis (DAIR) is generally accepted for acute infections. Various risk factors associated with treatment success have been described. The use of local antibiotic carriers (beads and sponges) is relatively unknown. We retrospectively analyzed risk factors in a cohort of patients from 3 hospitals, treated with DAIR for PJI.Patients and methods 91 patients treated with DAIR for hip or knee PJI in 3 Dutch centers between 2004 and 2009 were retrospectively evaluated. The mean follow-up was 3 years. Treatment success was defined as absence of infection after 2 years, with retention of the prosthesis and without the use of suppressive antibiotics.Results 60 patients (66%) were free of infection at follow-up. Factors associated with treatment failure were: a history of rheumatoid arthritis, late infection (> 2 years after arthroplasty), ESR at presentation above 60 mm/h, and infection caused by coagulase-negative Staphylococcus. Symptom duration of less than 1 week was associated with treatment success. The use of gentamicin sponges was statistically significantly higher in the success group, and the use of beads was higher in the failure group in the univariate analysis, but these differences did not reach significance in the logistic regression analysis. Less surgical procedures were performed in the group treated with sponges than in the group treated with beads.Interpretation In the presence of rheumatoid arthritis, duration of symptoms of more than 1 week, ESR above 60 mm/h, late infection (> 2 years after arthroplasty), and coagulase-negative Staphylococcus PJI, the chances of successful DAIR treatment decrease, and other treatment methods should be considered.

No abstract

Background: Little is known about functional outcome and quality of life (QoL) after one-stage revision for periprosthetic joint infection (PJI) of the hip.Methods: a cohort of 30 subjects treated with one-stage revision between 2011 and 2015 was identified, and questionnaires on functional outcome and QoL were distributed.Results: 28 subjects were successfully treated (93%). Most subjects were referred from other hospitals. Coagulase-negative Staphylococcus was found in 50% of the cases, and 40% of all cultured bacteria were multidrug-resistant. 25% had subsequent revision surgery, unrelated to PJI. Functional outcome was good and QoL scores were high, comparable to prosthetic joint revision surgery in general.Conclusion: Although the cohort was small and statistical analysis was not performed, this study showed that excellent results can be obtained with one-stage revision for hip PJI. Functional outcome and QoL was comparable to prosthetic joint revision surgery in general.

Forearm fractures in children are common. When conservative treatment fails, internal fixation with Elastic Stable Intramedullary Nailing (ESIN) become the first choice in the operative treatment of diaphyseal forearm shaft fractures. Refractures with the intramedullary nail in situ are known to occur but formal guidelines to guide management in such fractures are lacking. We present a well-documented case of a radius midshaft refracture in a 12-year-old boy with the intramedullary nail in situ, managed by closed reduction. Literature is reviewed for this type of complication, the treatment of 30 similar cases is discussed and a treatment strategy is defined.The refracture of the paediatric forearm fracture with the intramedullary nail in situ is a rare, but probably under recognised complication which is observed in approximately 2.3% of the study population. Closed reduction may be considered in these cases.

IntroductionThe incidence of vascular injuries after total hip arthroplasty is extremely low. In this report we describe an unusual injury to the common femoral artery.Case presentationA 59-year-old Caucasian woman presented with rest pain, numbness and cramps in the operated limb after hip replacement. Cement leakage under the transverse ligament had caused occlusion of the common femoral artery necessitating vascular reconstruction. She had a good functional recovery at follow-up.ConclusionTo the best of our knowledge, this is the first well-documented case reporting this pathomechanism of vascular lesion to the femoral artery. This case report highlights the potential risk of such a limb-threatening complication, and awareness should lead to prevention by meticulous surgical technique (correct technique of pressurization) or to early detection of the lesion.

This report describes the radiological and histological findings of a small cell osteosarcoma of a toe phalanx in a 38 year old man. This man presented with pain, swelling and redness of the left third toe. Medical history revealed an osteomyelitis of this toe eight years prior. Based on clinical findings and medical history the lesion was diagnosed as an osteomyelitis. However, peroperatively the lesion had a malignant aspect. Histological examination revealed a small cell osteosarcoma of the proximal phalanx.Osteosarcoma of the foot and especially of the tubular bones is rare. Moreover small cell osteosarcoma is a rare subtype of osteosarcoma. This case demonstrates that medical history and clinical examination can be misleading. In patients with apparent bone destruction, a malignancy must always be excluded prior to treatment. It emphasises the care that should be taken in the process of formulating a diagnosis.

The management of patients with an apparently normal functional total knee arthroplasty (TKA) suffering from unexplained persistent pain and swelling is a challenging issue. The usual causes of pain after total knee replacement are well known, but there are a small number of patients in whom its aetiology is obscure. Malfunction due to soft tissue impingement has rarely been reported. A patient with an unusual case of posterior soft tissue impingement secondary to a trapped posterior horn of a remnant medial meniscus after TKA and responsible for severe early polyethylene wear, is reported. The diagnosis was confirmed by arthroscopy. Treatment was performed by arthrotomy. The meniscus remnant was removed followed by total synovectomy and isolated exchange of the polyethylene insert. To our knowledge, this is the first well-documented case reporting this association. Case presentationA 63-year old male patient with a history of symptomatic osteoarthritis of the left knee underwent a Total Knee Arthroplasty (TKA) of posterior cruciate ligament retaining design (Kinemax, Stryker, Mahwah, New Jersey, USA) without a patella component. The postoperative course was uneventful. Three weeks later he presented to our out patient clinic with sudden swelling and discomfort of his left knee. Clinical examination demonstrated medial joint line tenderness and confirmed the patient's impression of joint effusion. Radiographs demonstrated a well-aligned TKA. All complaints, with exception of the knee effusion, declined progressively over a period of months. Two years postoperatively, the patient developed increasing pain and complained of "catching" of the knee. Physical examination showed a stable knee with a normal range of motion of 130 degrees flexion with no extension deficit. There was a moderate swelling and joint line tenderness medially. Standard radiographs showed a well-aligned TKA with no signs of loosening or polyethylene wear (Figure 1). Laboratory analysis including a complete blood count with differential, erythrocyte sedimentation rate, Creactive protein and knee aspiration for cell count and culture excluded infection. A technetium 99m diphosphonate bone scintigraphy showed an increased perfusion in the early phase and increased uptake in the static phase at the medial side of the femoral and tibial component and in the patella of the left knee (Figure 2).A diagnostic arthroscopy was performed to differentiate between a mechanical and a soft tissue related problem. Arthroscopy revealed a remnant of the posterior horn of the medial meniscus impinging between the posterior part of the femoral component and the polyethylene insert. There was also an important delamination of the anteromedial part of the insert with a crack at the ventral

No abstract