Background. There are few cases of entire femur modular replacement with hip and knee joints in patients with periprosthetic joint infection (PJI) in literature. They report encouraging results in patients of elderly and senile age. We present case of a copper-coated femoral spacer implantation to 50-year-old patient with multiple PJI episodes and osteomyelitis of the entire femur.Clinical presentation. A 40-year-old male patient after resection of the proximal part of the right femur for fibrotic osteodysplasia underwent total hip arthroplasty with replacement of 15 cm of the femur. In December 2010 (20 months after implantation), instability of the femoral component developed, revision arthroplasty was performed with stem recementation. After 4 months, sinus tract formed in the area of the postoperative scar. After another 4 months, the head of the prosthesis was dislocated. In September 2011, the endoprosthesis components were removed and a unipolar cement spacer was implanted. The limb immobilized in a hip spica cast. Methicillin-sensitive S. epidermidis (MSSE) was detected in the preoperative joint aspiration puncture and periprosthetic tissues. After 3 months (December 2011), patient underwent revision total hip arthroplasty (25 cm defect was replaced). 5 years of PJI remission followed. In November 2016 after PJI recurrence the endoprosthesis was removed, and an articulating spacer was implanted. P. aeruginosa was detected in periprosthetic tissues. For the past 2.5 years there were periodically sinus tracts formations. In August of 2019 spacer’s migration resulted in an intercondylar fracture of the right femur. In September 2019, spacer was removed, and MSSE was detected in the surrounding tissues. An articulating cement spacer based on an oncological modular total femur coppercoated endoprosthesis was implanted. At each control examination during the year copper concentration in blood serum was determined, it did not exceed 900–1200 mcg/l. No local or systemic side effects were detected. The patient started working 3 months after surgery. After 6 months poor functioning sinus tract formed in the postoperative scar area in the lower third of the thigh. 1.5 years after the operation, the functional condition is satisfactory.Conclusion. The use of the copper-coated spacer based on modular total femur endoprosthesis with hip and knee joints in a patient with multiple PJI allowed to improve the function of the limb and reduce the severity of the infectious process. No local or systemic toxic effects of copper were detected.
The importance of measuring of the angle between the mechanical and anatomical femoral axis (fVa) during the preoperative total knee arthroplasty (TKa) planning is not recognized by all. Some surgeons believe that it is acceptable to set distal femoral resection guide at 6° or 7° in all cases or adjust femoral resection guide fVa accordingly with patient height. We conducted two studies. one-retrospective analysis of radiographs of patients with TKa performed since 1.09.2014 till 31.01.2015 (n = 261, 273 TKa). In this cohort, we were looking for correlation between the parameters obtained on long hip-knee-ankle radiographs (fVa, coronal knee alignment) and gender, age, body mass index (BMI) and height, as well as the implant model and the level of constraint. after that we conducted a prospective, randomized trial with TKa performed since 1.02.2015 till 31.05.2015 (n = 225, 225 TKa). The patients were randomly divided into two groups. In the "individual fVa" group (n = 121), the distal femoral resection guide fVa was set accordingly with measured fVa, in the control group (n = 104)-at 7° (average fVa for the Sverdlovsk area patients' population). We compared TKa x-ray results of both groups. Results. first stage. We found no correlation between fVa and age, BMI, height and sex of patients (p>0.05). after TKa residual varus deformity of more than 3° (malalignment) (3.9±1.06) was observed in 7% of cases (19 joints). We found correlation between coronal knee malalignment after TKa and two factors: BMI and initial severity of varus deformity (p = 0.003 and p<0.001). Second stage. In the control group we've seen femoral component deviation of more than 3° from the perpendicular to neutral mechanical axis (malposition) 3 times more often then in the "individual fVa" group (9 vs. 3, p = 0.021). Conclusions. We did not identify the dependence of fVa on sex, age, BMI and height. With initial varus of more than 20° and BMI of more than 30 kg/m 2 , the risk of coronal components malalignment is increased. The average fVa in patients of Sverdlovsk area is 6,7±1,5° (3-11°). Implementation of preoperative fVa measurement and following femoral distal cut adjustments improves femoral component positioning and overall leg alignment postoperatively.
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