[show abstract][hide abstract] ABSTRACT: Periprosthetic infections (PPI) represent one of the most complex complications in arthroplasty concerning both, diagnosis and therapy. The incidence of PPI of the hip is approximately 1 % after primary procedures and 4 % after revision surgery. About two thirds of PPIs occur via intraoperative contamination and the remaining PPIs are acquired by hematogenous seeding.
This article presents an overview of up to date evidence-based diagnostics and therapy of PPI of the hip with the establishment of a clear algorithm.
A selective literature search was carried out with the inclusion of own work.
A PPI must be actively excluded in cases of a painful prosthesis or signs of loosening within the first years after implantation. Measurement of C-reactive protein (CRP) can be normal especially in cases of chronic (low grade) PPI and cannot be used as an exclusion criterion. The standard diagnostic procedure includes preoperative joint aspiration with culture and leukocyte counts as well as culture and histology of periprosthetic tissue. Imaging techniques, such as magnetic resonance imaging (MRI) and scintigraphy are of inferior significance. Newer methods, such as sonication of removed implants have revolutionized the diagnostics and several cases which had previously been considered aseptic loosening failures have now been reclassified as PPI. Essential parameters for the treatment algorithm are maturity of the biofilm, stability of the prosthesis, the causative organism and the state of the soft tissue. Retention of the prosthesis can only be considered when the biofilm is still immature (acute PPI). In chronic (low grade) PPI eradication of the infection can only be achieved by exchanging the prosthesis. This has to be performed either as a one-stage procedure or as a two-stage exchange with a short (2-4 weeks) or a long (> 6 weeks) interval. Biofilm active antibiotics play an essential role in the treatment of PPI and have to be used as targeted therapy.
Successful therapy and diagnostics of PPI require following an exact algorithm. The interdisciplinary cooperation between specialists for infectious diseases and microbiologists represents a decisive factor.
[show abstract][hide abstract] ABSTRACT: Luxation following endoprosthetic hip replacement represents a frequent and severe complication and is the reason for a relevant number of hip arthroplasty revision interventions. The probability of occurrence of luxation of a total hip arthroplasty is associated with the indications, patient and operation-specific risk factors. Approximately 50 % of luxations after total hip arthroplasty occur within 3 months of the operation (early luxation).
The diagnostics of luxation of total hip arthroplasty are carried out by clinical and radiological methods. The causative assignment is made by assessment of joint stability, the bony situation (e.g. loosening, periprosthetic fracture and defects) and the soft tissue (e.g. pelvitrochanterian musculature). In cases of clinical and paraclinical signs of infection and of late luxations, a joint puncture is indicated.
Therapy decisions are made depending on the cause (e.g. implant malpositioning, pelvitrochanterian insufficiency, impingement, incongruence between head and inlay and combinations of causes). Therapy of acute total hip prosthesis luxation begins with imaging controlled repositioning carried out with the patient under adequate analgesia and sedation. Conservative therapy is carried out by immobilization with a hip joint orthesis or pelvis-leg cast for 6 weeks. Operative therapy strategies for recurrent luxation are restoration of the correct implant position and sufficient soft tissue tension. Larger hip heads, bipolar heads and tripolar cups are more commonly used due to the geometrically lower probability of dislocation (higher jumping distance). Luxation of total hip prostheses due to infection is treated according to the principles of periprosthetic infection therapy. The rate of recurrence of luxation of 30 % is high so that in cases of unsuccessful therapy treatment should best be carried out in a center for revision arthroplasty.
The search for the exact cause of total hip prosthesis luxation is extremely important. A classification is only possible when the exact cause is known and together with patient and implant-specific details the therapeutic approach can be ascertained. In revision operations the intraoperative functional diagnostics must be exactly documented. The reasons for delayed luxations could be prosthesis infections, abrasion and loosening.
[show abstract][hide abstract] ABSTRACT: Tumorous destruction of the periacetabular region and the proximal femur are a consequence of either primary malignant bone tumor manifestation or metastatic disease, which is observed much more frequently and occurs typically in these skeletal segments. Pathological fractures of the proximal femur and periacetabular regions of the pelvis have a high incidence and ultimately lead to severe pain and immobilization.
Advanced resection techniques and different types of defect reconstruction, allowing for oncologically sufficient resection of extensive tumors have contributed to a marked increase in the limb salvage rate. However, these procedures are associated with an increasing rate of several, sometimes severe intraoperative and postoperative complications.
Compared to elective total hip arthroplasty, the rate of postoperative deep infections, dislocations, the incidence of pathological and periprosthetic fractures and the prevalence of deep vein thrombosis are increased with high rates of postoperative mortality and local tumor recurrence, being the most serious complications. Pelvic involvement and subsequent periacetabular resection have the highest complication rate when compared to proximal femur resection with endoprosthetic treatment.
In order to minimize the risk of these intraoperative and postoperative complications wide resection and advanced reconstruction as well as complicated palliative stabilization due to malignant bone tumor growth around the hip joint should be performed in musculoskeletal tumor centers with profound expertise in osteosynthetic and endoprosthetic reconstruction of the pelvis and the proximal femur. Only in specialized centers an effective, multidisciplinary emergency management of these complications and, more importantly, reliable prevention of complications can be ensured.
[show abstract][hide abstract] ABSTRACT: Hintergrund
Tumoröse Destruktionen der periazetabulären Region und des proximalen Femurs können durch primäre, zumeist maligne Knochentumoren verursacht sein, sind aber ungleich häufiger die Folge metastastischer Läsionen. Unter allen Skelettabschnitten weist diese Region die höchste Rate pathologischer Frakturen auf.
Fortgeschrittene Resektionstechniken, welche die onkologisch suffiziente Resektion selbst ausgedehnter Tumormanifestationen erlauben, und die Einführung moderner osteosynthetischer und endoprothetischer Rekonstruktionsmethoden für Becken und Femur, haben zu einer deutlichen Steigerung extremitätenerhaltender Eingriffe geführt, weisen aber auch eine Reihe typischer und schwerwiegender intra- und postoperativer Komplikationen auf.
Neben der im Vergleich zur elektiven Hüftendoprothetik erhöhten Rate von Infekten, septischen/aseptischen Lockerungen, Luxationen, periprothetischen und pathologischen Frakturen und tiefen Becken-/Beinvenenthrombosen stellen die erhöhte intra- und postoperative Mortalität und das lokale Tumorrezidiv die schwerwiegendsten Komplikationen dar. Insgesamt weisen periazetabuläre Resektionen im Vergleich zur proximalen Femurresektion mit endoprothetischer Versorgung eine erhöhte Komplikationsrate auf.
Um die Rate der intra- und postoperativen Komplikationen gering zu halten, sollte die Durchführung ausgedehnter kurativer und palliativer Resektionen muskuloskelettalen Tumorzentren mit ausgewiesener Expertise in osteosynthetischen und endoprothetischen Rekonstruktionsverfahren von Becken und Femur vorbehalten sein. Nur dort können eine effektive Komplikationsprophylaxe und – falls erforderlich – ein adäquates, interdisziplinäres Komplikationsmanagement sofort erfolgen.
[show abstract][hide abstract] ABSTRACT: Due to the marginal periarticular soft tissue envelope and the high risk of concomitant soft tissue or periprosthetic infection with the presence of exposed metal or bone, soft tissue defects after total knee arthroplasty are always a relevant surgical problem. Specific patient-related, intra- and postoperative risk factors have been identified and need to be considered during the course of treatment. Often a profound management of underlying infection must accompany the staged defect treatment which could require a prosthesis explantation with secondary revision in the case of a deep infection and involvement of the prosthesis. Four stages of soft tissue defects have been introduced (types A-D) and criteria for differentiation are the overall soft tissue coverage, the exposure, respectively, necrosis of the extensor mechanism, preservation or involvement of the joint capsule and/or an accompanying septic loosening of the prosthesis. The concept of plastic coverage follows a stage-adapted algorithm and includes secondary wound healing and mesh coverage for superficial defects, fasciocutaneous flaps for moderate defects and pedicled or free muscle flaps for deep defect situations with extension into the joint capsule. Crucial factors for a successful therapy include the early identification and precise analysis of defect characteristics, the careful preparation of the wound bed with serial debridements and the diligent flap coverage with early consultation of plastic-surgical expertise.
[show abstract][hide abstract] ABSTRACT: We report the case of symptomatic extra-articular subspinal impingement in the hip joint caused by a pathological contact between the anterior inferior iliac spine (AIIS) and the femoral neck. A 28-year-old patient presented with activity-related inguinal pain on the right side and a positive anterior impingement test in the clinical examination. Radiological examinations revealed a hypertrophic AIIS with caudal extension below the acetabulum. After a positive injection test confirmed the AIIS as the origin of the pain, arthroscopic correction with partial resection of the AIIS was performed resulting in significant pain relief and improved range of motion.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Men show better functional results after total hip arthroplasty (THA). The aim of this study was a patient-specific analysis of the hip joint muscles in comparison to the joint geometry. METHODS: In this study 93 computed tomography (CT) scans of the pelvis (45 men, 48 women) were analyzed to determine hip joint geometry and the volume of the gluteus medius (GMV), gluteus maximus (GXV) and tensor fasciae latae (TFL) muscles. The abduction muscle volumes were analyzed with respect to patient-specific adduction moments. RESULTS: The absolute total volume of the hip muscular system (TMV) was larger in men than in women (1913 ccm vs. 1479 ccm; p <0.0001). Men exhibited a more progressive increase of muscle volume as the adduction moment increases. CONCLUSIONS: Men have a greater abduction muscle mass in order to balance adduction moments occurring in the hip joint and therefore have more muscle mass to compensate the inevitable intraoperative muscle damage during THA. This argument supports the extraordinary importance of muscle sparing surgical techniques in women.
[show abstract][hide abstract] ABSTRACT: Even tissues capable of complete regeneration, such as bone, show an age-related reduction in their healing capacity. Here, we hypothesized that this decline is primarily due to cell non-autonomous (extrinsic) aging mediated by the systemic environment. We demonstrate that culture of mesenchymal stromal cells (MSCs) in serum from aged Sprague-Dawley rats negatively affects their survival and differentiation ability. Proteome analysis and further cellular investigations strongly suggest that serum from aged animals not only changes expression of proteins related to mitochondria, unfolded protein binding or involved in stress responses, it also significantly enhances intracellular reactive oxygen species production and leads to the accumulation of oxidatively damaged proteins. Conversely, reduction of oxidative stress levels in vitro markedly improved MSC function. These results were validated in an in vivo model of compromised bone healing, which demonstrated significant increase regeneration in aged animals following oral antioxidant administration. These observations indicate the high impact of extrinsic aging on cellular functions and the process of endogenous (bone) regeneration. Thus, addressing the cell environment by, for example, systemic antioxidant treatment is a promising approach to enhance tissue regeneration and to regain cellular function especially in elderly patients.
Cell Death & Disease 01/2013; 4:e970. · 6.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: PURPOUSE OF THE STUDY Wound drainage in surgical interventions has a long tradition. Regarding the primary TKA there are no valid data concerning the ideal point of time for removal. The objective of this prospective randomized study was to investigate which drainage procedure should be given preference with regard to wound healing, blood loss, development of intraarticular hematomas and early postoperative function. MATERIAL AND METHODS We documented the ROM, the knee circumference at the upper patellar pole preoperatively and on days 2, 4 and 6 postoperatively. The blood volume and loss was calculated. As surrogate parameter for wound healing we counted the amount of days until no residual secretion was observed via the wound/drainage site. RESULTS The results of our investigation do not show any significant difference with regard to the mentioned parameters. CONCLUSIONS In our investigation, we were unable to find any significant advantage of intraarticular drainage for 48 hours over 24 hours after primary total knee arthroplasty. After uncomplicated total knee arthroplasty we recommend removing drainage after 24 hours. Key words: knee arthroplasty, intraarticular drainage, postoperative hematomas, infection, blood loss.
[show abstract][hide abstract] ABSTRACT: Biological stimuli such as growth factors have proven their enormous potential to initiate
healing even in severe clinical cases. Potent biological stimuli would benefit from a local
delivery and the opportunity to be combined with conventional implants. In addition, the
specific biological need of the patient frequently becomes obvious just in the intra-operative
setting. We hypothesized that a patch concept that allows rapid attachment to an implant
surface represents as a potential solution for the technical challenging concept of personalized
local drug delivery.
Dexamethasone loaded poly[(rac-lactide-co-glycolide] microparticles were embedded within
a polyvinyl alcohol (PVA) patch that was attached onto metal implant surfaces by in-situ
polymerization of alkyl-2-cyanoacrylates (CA). The incorporation of hydroxyapatite (HA)
nanoparticles into PVA enabled to control the cyanoacrylate penetration within the patch and
improved significantly the attachment, while no interference with the drug release was
observed. Double layered patches with one layer for drug delivery and one layer as gluing
interface could represent a solution strategy for safe and controlled local drug delivery from
implant surfaces or other, even biological, materials. The presented technology platform
opens the opportunity for personalized medicine by allowing local administration of drugs
with customized release due to intra-operative application.
Expert Opinion on Drug Delivery 01/2013; · 4.87 Impact Factor
[show abstract][hide abstract] ABSTRACT: Combined fractures of the greater and the lesser tuberosity are very rare injuries. This is a case report on arthroscopic treatment using suture anchors and one distal fixation screw. Clinical and radiographic follow-up showed recovery of active motion and consolidation of the fragments in anatomic positions. Level of evidence V.
Knee Surgery Sports Traumatology Arthroscopy 05/2012; · 2.68 Impact Factor
[show abstract][hide abstract] ABSTRACT: Dislocations after total hip arthroplasties are one of the most common complications of the procedure. According to registers, recurrent hip dislocations account for up to 30 % of the indications for a revision operation. The incidence of a dislocation is influenced by indication-associated, patient-dependent and operation-specific risk factors. 50 % of the dislocations occur within the first 3 months which confirms the high relevance of operation-specific influencing factors. The diagnosis is almost always made with the help of computed tomography, as this is the only method to determine the three-dimensional relationship of the components. A dynamic fluoroscopic examination can verify an increased translation (reduced soft-tissue tension) and thus enables a functional examination to determine the mechanism of the dislocation. By means of a classification of dislocations into five types under consideration of the implant position, the sufficiency of the pelvitrochantar musculature, the presence of an impingement, the congruence of head and acetabular liner as well as combinations of these factors it is possible to plan an adequate therapy. From the therapeutic point of view the correct positioning of the stem and head is of decisive importance. In addition therapeutic success can be realized by using larger head diameters through to tripolar sockets, reconstruction of soft tissues and, last but not least, an adequate postoperative immobilization. Even so, this treatment is associated with a high rate of complications and in the literature failure rates of up to one third, i.e., the reoccurrence of a dislocation, are reported.
[show abstract][hide abstract] ABSTRACT: Total hip arthroplasty to create an articulating hip joint. Acetabular cup implantation in the original rotational center of the pelvis. Simultaneous femoral shortening osteotomy to prevent neurovascular damage and equalize leg length in patients with unilateral occurrence.
Developmental dysplasia of the hip (DDH) in adults; type 3 and 4 dislocation according to Crowe.
Cerebrospinal dysfunction with permanent restriction of coordination ability, muscular dystrophies, and multiple malformations of the musculoskeletal system. Apparent disturbance of the bone metabolism.
The Watson-Jones interval approach to the hip joint is used to avoid functional disorders of the hip abductors. After preparation of the proximal femur and femoral neck resection, adjustment of the non-regularly developed acetabular cavity with reduced anterior coverage takes place. The cup component is implanted and the interval between the vastus intermedius and the vastus lateralis below the lesser trochanter examined. Loss of periosteum of the femoral cortex due to blunt spreading is to be avoided. Following the femoral shortening osteotomy initially the preparation of the distal bone segment takes place to adjust the endofemoral canal for shaft implantation in the following preparation of the metaphyseal segment. Afterwards osteotomy-bridging implantation of a cementless, distal anchoring stem design is performed.
Partial weight bearing of the leg with 20 kp is necessary for 6 weeks combined with therapy of existing contractures and active pelvic rotation training. Within 10 postoperative weeks full weight bearing is usually reached. After this period mobilization without crutches is possible. Inpatient rehabilitation is possible after bony recovery of the femoral osteotomy.
From 1993 to 1999, the first 15 total hip arthroplasties were performed in adult patients with DDH; they were treated with simultaneous femoral shortening osteotomy and without additive osteosynthesis. During the midterm follow-up (4.3 years), no failure of the femoral component was observed with complication-free osseous healing of the osteotomy. One cup revision was necessary in this period. The Merle d'Aubigné score increased from 8.2 preoperatively to 15.5 points.
Operative Orthopädie und Traumatologie 03/2012; 24(2):109-15. · 0.47 Impact Factor
[show abstract][hide abstract] ABSTRACT: Introduction: The present feasibility study examined the use of an ultrasound-based navigation system (UNS) for reliability of measurement the positions of both the femoral and acetabular components, a prerequisite to adjust the combined anteversion with sufficient accuracy when using a femur-first approach in total hip arthroplasty. Method: Using a UNS, five investigators performed five measurements of the posterior femoral condyles and the anterior pelvic planes (APP) of two cadavers with different body mass index. Deviations in stem and acetabular anteversion resulting from varying acquisition of the respective landmarks were determined relative to the reference measures of anteversion determined in the same cadavers from computed tomography (CT) scans. Here, both a freehand and guided ultrasound measurement methods were used to acquire the posterior femoral condyles. Femoral and acetabular anteversion values were added in order to estimate the combined anteversion of the reconstructed hip. Results: Using an UNS, variations in the freehand technique for the acquisition of the posterior femoral condyles resulted in a mean error in the anteversion of the femoral component of -1.5° (SD 3.4°; -10.8° to 7.0°) while the mean error was -0.9° (SD 3.1°; -7.3° to 10.2°) when the UNS provided additional support to standardize the orientation of the UNS probe. In all cases, UNS navigation enabled to achieve combined anteversion values that fell within a clinically acceptable error range of less than ± 12.5° compared to the CT measures. Conclusion: Our investigations suggest that the anteversion of stem and cup can be measured with accuracy sufficient enough to utilize the concept of combined anteversion using UNS. Hence, the advantage of utilizing UNS's in a femur-first approach is the ability to intraoperatively compensate for deviations from the targeted anteversion of the stem (which is often difficult to control) by adjusting the acetabular anteversion in the final step of the implantation. In doing so, the placement of the components follows the concept of combined anteversion. Avoiding extreme anteversion values of combined anteversion could be an important step towards reducing post-operative complications following total hip arthroplasty (THA).
Technology and health care: official journal of the European Society for Engineering and Medicine 01/2012; 20(6):535-43. · 0.64 Impact Factor
[show abstract][hide abstract] ABSTRACT: Effective treatment of periprosthetic fractures following TKA continues to represent a surgical challenge. The incidence and frequency of these complicated type of fractures is expected to increase as the number of TKA as well as the activity level of these patients steadily rises. A careful and correct analysis of the fracture pattern, its classification, the quality of the existing bone stock and the fixation / loosening of the underlying prosthetic system has to precede decision making for successful conservative or surgical treatment. Therefore, improved diagnostic radiographic imaging of fracture patterns and reliable assessment of prosthesis loosening progressive development of new implant methods and refinement of soft tissue preserving surgical techniques will hold the key for regaining the functional level prior to the fracture.