Jeffrey J. Sewecke

Arthrodesis of the Knee with a Long Intramedullary Nail Following the Failure of a Total Knee Arthroplasty as the Result of Infection

BACKGROUND Knee arthrodesis can be an effective treatment option for relieving pain and restoring some function after the failure of a total knee arthroplasty as the result of infection. The purpose of the present study was to review the outcome of a staged approach for arthrodesis of the knee with a long intramedullary nail after the failure of a total knee arthroplasty as the result of infection. METHODS We reviewed the results for twelve patients who underwent knee arthrodesis after the removal of a prosthesis because of infection. The study group included seven women and five men who had an average age of sixty-eight years at the time of the arthrodesis. All patients were managed with a staged protocol. Implant removal, débridement, and insertion of antibiotic cement spacers was followed by the administration of systemic antibiotics. Provided that clinical and laboratory data suggested eradication of the infection, arthrodesis of the affected knee with use of a long intramedullary nail was carried out. Clinical and laboratory evaluation and radiographic analysis were performed after an average duration of follow-up of 4.1 years. RESULTS Solid union was achieved in ten of the twelve knees. The average time to union was 5.5 months. One patient had an above-the-knee amputation because of recurrence of infection. In another patient, nail breakage occurred three years following implantation. The average limb-length discrepancy was 5.5 cm. The mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 41 to 64 points. None of the seven patients who underwent arthrodesis with a technique involving convex-to-concave reamers had a complication, and the average time to union for these seven patients was shorter than that for the remaining five patients (4.3 compared with 7.4 months). CONCLUSIONS We believe that obtaining large surfaces of bleeding contact bone during arthrodesis following staged treatment of an infection at the site of a failed total knee arthroplasty contributes to stability and enhances bone-healing. Staged arthrodesis with use of a long intramedullary nail and convex-to-concave preparation of bone ends provided a painless functional gait with low complication and reoperation rates in this challenging group of patients.

Arthrodesis of the knee with a long intramedullary nail following the failure of a total knee arthroplasty as the result of infection : Surgical technique

BACKGROUND Knee arthrodesis can be an effective treatment option for relieving pain and restoring some function after the failure of a total knee arthroplasty as the result of infection. The purpose of the present study was to review the outcome of a staged approach for arthrodesis of the knee with a long intramedullary nail after the failure of a total knee arthroplasty as the result of infection. METHODS We reviewed the results for twelve patients who underwent knee arthrodesis after the removal of a prosthesis because of infection. The study group included seven women and five men who had an average age of sixty-eight years at the time of the arthrodesis. All patients were managed with a staged protocol. Implant removal, débridement, and insertion of antibiotic cement spacers was followed by the administration of systemic antibiotics. Provided that clinical and laboratory data suggested eradication of the infection, arthrodesis of the affected knee with use of a long intramedullary nail was carried out. Clinical and laboratory evaluation and radiographic analysis were performed after an average duration of follow-up of 4.1 years. RESULTS Solid union was achieved in ten of the twelve knees. The average time to union was 5.5 months. One patient had an above-the-knee amputation because of recurrence of infection. In another patient, nail breakage occurred three years following implantation. The average limb-length discrepancy was 5.5 cm. The mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 41 to 64 points. None of the seven patients who underwent arthrodesis with a technique involving convex-to-concave reamers had a complication, and the average time to union for these seven patients was shorter than that for the remaining five patients (4.3 compared with 7.4 months). CONCLUSIONS We believe that obtaining large surfaces of bleeding contact bone during arthrodesis following staged treatment of an infection at the site of a failed total knee arthroplasty contributes to stability and enhances bone-healing. Staged arthrodesis with use of a long intramedullary nail and convex-to-concave preparation of bone ends provided a painless functional gait with low complication and reoperation rates in this challenging group of patients.

CT-Guided Iliosacral Screw Placement: Technique and Clinical Experience

OBJECTIVE The purpose of this study was to describe the technique of and experience in using CT guidance for percutaneous iliosacral screw placement in patients with unstable pelvic fractures. CONCLUSION CT-guided iliosacral screw placement is a safe and accurate procedure that can be performed by radiologists in a radiology suite.

Revision Total Hip Arthroplasty with a Custom Cementless Stem with Distal Cross-locking Screws: Early Results in Femora with Large Proximal Segmental Deficiencies

BACKGROUND Revision total hip arthroplasty in the setting of a large proximal segmental femoral deficiency and/or discontinuity between the proximal and distal parts of the femur remains a challenging problem. We describe the use of a cementless stem with distal cross-locking screws to provide stability of the femoral implant in this situation. METHODS Seventeen custom fully porous and hydroxyapatite-coated titanium femoral stems with distal cross-locking titanium screws were implanted in sixteen patients during revision total hip arthroplasty. Preoperatively, all of the patients had Paprosky grade-IIIB or IV femoral deficiencies. At the time of follow-up, the Harris hip scores were calculated and radiographs were made. A successful result was defined as a postoperative increase in the Harris hip score of >20 points, a radiographically stable implant, and no additional femoral reconstruction. RESULTS At the time of final follow-up, at a mean of 5.3 years postoperatively, the result was successful in sixteen of the seventeen hips, the mean Harris hip score had improved from 35 to 76 points, and all implants were clinically and radiographically stable. There were no postoperative infections or hip dislocations. CONCLUSIONS The use of a custom femoral stem with distal cross-locking screws can provide at least intermediate-term clinical and radiographic stability in patients with Paprosky grade-IIIB or IV femoral deficiencies. Longer follow-up will be required to determine the longevity of these implants.

Survival of Primary Condylar-Constrained Total Knee Arthroplasty at a Minimum of 7 Years

The purpose of the present study is to retrospectively analyze clinical and radiographic outcomes in primary constrained condylar knee arthroplasty at a minimum follow-up of 7 years. Given the concern for early aseptic loosening in constrained implants, we focused on this outcome. Our cohort consists of 127 constrained condylar knees. The mean age of patients in the study was 68.3 years, with a mean follow-up of 110.7 months. The diagnosis was primary osteoarthritis in 92%. There were four periprosthetic distal femur fractures, with a rate of revision of 0.8%. No implants were revised for aseptic loosening. Kaplan-Meier survivorship analysis with removal of any component as the end point revealed that the 10-year rate of survival of the primary CCK was 97.6% (95% CI, 94%-100%).

Demonstration of bacillus cereus in orthopaedic-implant-related infection with use of a multi-primer polymerase chain reaction-mass spectrometric assay: report of two cases

Infection following primary total joint replacement occurs with a prevalence of approximately 1% to 2%, but it can be a devastating complication1. Rates of infection following revision arthroplasty are higher, approaching 10%2,3. The medical and economic costs of periprosthetic joint infection are expected to become greater in the future, with the number of primary total hip arthroplasties expected to grow by 174%, to 572,000 annually in two decades4. Periprosthetic joint infections are associated with bacterial biofilms on and around the implants5-7. Differing from their single-celled planktonic counterparts, bacteria attached to surfaces in organized communities are more resistant to conventional antibiotic regimens and to host defense mechanisms; demonstrate greatly reduced growth and metabolic kinetics, linking them predominantly with chronic infections; and are difficult to isolate and propagate with use of standard microbiology culture methods8. As a consequence, biofilm-based infections can be difficult to diagnose and treat effectively. The problem of accurately diagnosing a periprosthetic joint infection is vexing. Often, the first step is to aspirate the site and culture specimens of the aspirate. Unfortunately, if the infection is biofilm-associated, standard culture results may be negative despite the presence of microbes. Adjunctive studies such as measurements of the erythrocyte sedimentation rate and C-reactive protein level have not proven definitive9, nor have imaging modalities such as a nuclear scan10. There are similar concerns about the diagnosis of infections associated with fracture fixation devices11. These infections have also been recognized as arising from biofilm bacteria and may exhibit the same resistance to diagnosis and treatment that is characteristic of biofilm bacteria in periprosthetic joint infection. As is the case with periprosthetic joint infection, cultures have identified staphylococcal species as the most common bacterial agents. …

Using Double-Contrast CT Arthrography to Confirm Suspected Dissociation of a Cemented Polyethylene Liner in the Setting of Revision Total Hip Arthroplasty

Case: A 67-year-old woman who underwent a re-revision of a total hip arthroplasty with a cemented polyethylene liner fell 14 months after surgery. The patient had symptoms of pain and weakness; however, clinical, laboratory, and radiographic evaluation did not disclose fracture, infection, osteolysis, or component migration. Liner dissociation was suspected, and a double-contrast computed tomography (CT) arthrogram confirmed failure at the cement-liner interface. She underwent additional revision surgery and was doing well at the 3-year follow-up. Conclusion: Double-contrast CT arthrography confirmed failure at the cement-liner interface and is an effective diagnostic tool in identifying suspected dissociations of cemented polyethylene liners.