Landor I

Total elbow replacement with the Souter-Strathclyde prosthesis in rheumatoid arthritis: LONG-TERM FOLLOW-UP

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.

The Long Oblique Revision component in revision arthroplasty of the hip

Migration of the acetabular component may give rise to oval-shaped bone defects in the acetabulum. The oblong implant is designed to fill these defects and achieve a stable cementless anchorage with no significant bone loss. We prospectively reviewed 133 oblong long oblique revision components at a mean follow-up of 9.74 years (0.6 to 14). All had been used in revisions for defects of type IIB to IIIB according to Paprosky. Aseptic loosening was the reason for revision in 11 cases (8.3%) and deep infection in seven (5.3%). The probability of implant survival over a 12-year follow-up estimated by the Kaplan-Meier method gave a survival rate of 0.85% respectively 0.90% when deep infection was excluded as the endpoint. Our study supports the use of these components in defects from IIB to IIIA. The main precondition for success is direct contact of more than half of the surface of the implant with the host acetabular bone.

Zweizeitige Operation zur Behandlung tiefer Infektionen bei Hüftendoprothesen unter Verwendung eines kanülierten Platzhalters

ZusammenfassungOperationsziel Einsetzen eines soliden antibiotikahaltigen PMMA-Platzhalters in der ersten Operation eines zweizeitigen Hüftrevisionseingriffs wegen tiefer Infektion bei Hüftendoprothese.Dadurch Vermeidung einer Beinverkürzung und Erreichen einer toxischen lokalen Antibiotikakonzentration. Indikationen Tiefe Infektion nach Hüfttotalendoprothesen, insbesondere wenn die Femurkomponente betroffen ist. Kontraindikationen Große Knochendefekte am proximalen Femur.Schlechter Allgemeinzustand, der keine Revisionsoperation mehr zulässt. Operationstechnik Entfernung beider Komponenten, ausgiebiges Débridement mit Entfernung des alten Zements. Intraoperative Formung eines kanülierten Spacers mit antibiotikahaltigem Knochenzement im Stil einer Moore-Prothese. Kanülierung mit einem Charrière-16-Redon-Drain, in den ein passender Kirschner-Draht eingeführt wird. Nach Aushärten des Zements Entfernung des Kirschner-Drahts und Kürzen des Drains. Ein Charrière-8-Drain wird in den Spacer geschoben, und die Hüfte wird reponiert. Ergebnisse Der Spacer wurde in 29 Fällen mit tiefem Hüftendoprotheseninfekt angewendet. Das Intervall zwischen Implantation des Spacers und Wiedereinbau einer Hüftendoprothese betrug 11,6 Wochen. Nach Spacerimplantation traten in zwei Fällen Reinfektionen auf, die ein zweites Débridement mit Implantation eines neuen Spacers und eine Spülung erforderten. Unsere Erfolgsrate mit dieser zweizeitigen Revisionsoperation beträgt 96,5%. Die Patienten erreichten im Harris-Hip-Score durchschnittlich 90,1 Punkte. Brüche des Spacers traten zweimal, Luxationen fünfmal auf; beide hatten keinen Einfluss auf das Endergebnis.AbstractObjective Eradication of infection through insertion of a solid antibiotic-loaded PMMA spacer during the first stage of a twostage reimplantation for deep infection to prevent shortening, to obtain a high local concentration of antibiotics in and to permit lavage of the medullary canal. Indications Deep infection after total hip arthroplasty (THA) in patients who are candidates for revision surgery, especially in instances where the infection is confined to the region of femoral component. Contraindications Large defect of proximal femur.Poor general health not allowing two procedures. Surgical Technique Extraction of both components, removal of all necrotic material and cement. Intraoperative manual modeling of a cannulated spacer using bone cement premixed with antibiotics, its shape resembling a Moores prosthesis. The spacer is shaped around a size 16 drain into which a corresponding Kirschner wire is inserted. Once the spacer is completely set, the Kirschner wire is removed and the drain shortened. A size 8 lavage drain tube is then inserted into the spacer and the hip reduced. Results We used the spacer in the treatment of 29 patients with infected THA. The interval between spacer implantation and insertion of the total hip implants was 11.6 weeks. Reinfection after implantation of the spacer was observed twice necessitating a second debridement, implantation of a new spacer, and lavage. Success rate of two-stage revision was 96.5%. The Harris hip score reached an average of 90.1 points. Breakage of the spacer was observed twice, and dislocation occurred in five patients; both did not affect the final result.

Treatment of orthopedic infections caused by resistant staphylococci.

During 1999–2005 we treated 15 patients with linezolid for relevant infections of locomotion apparatus (7 cases with endoprosthesis infection, 5× osteomyelitis and 3× another infection). With the exception of one case the antibiotic therapy was always combined with appropriate surgical intervention. Average period of linezolid administration was 26 d; linezolid was applied from the beginning intravenously on average for 10 d, and then orally for 16 d (average). There were no undesirable effects in the file. Success rate reached 86.6 %. MRSA strains were proved by standard methods: growth on Mueller-Hinton agar with increased concentration of NaCl and 2 mg/L of oxacilline, and measuring inhibitory zones around cephoxitine disk. The sensitivity to other antibiotics was specified by disk-diffusion test; that to linezolid was verified by E-test. Linezolid represents a medical reserve for the treatment of multiresistant Gram-positive infections or for emergencies, when allergy onset, high toxicity risk, intolerance,etc. do not allow to use other,in vitro effective, antibiotics.

Bone grafts as vancomycin carriers in local therapy of resistant infections

The level of an antibiotic capable of inhibiting the etiological agent at the site of infection is an essential prerequisite for successful antibiotic therapy. In some cases, locally applied antibiotics may compensate for limitations of systemic administration and shorten systemic therapy. We aimed at verifying to what extent vancomycin (Van) bound to ground bone grafts is usable in the treatment of serious infections. The levels of released Van significantly exceeded the Van minimum inhibitory concentration, which can suppress Van-sensitive staphylococci and Van intermediate Staphylococcus aureus, for the whole period of a 16-day measurement. Our results indicate that bone grafts can be used as Van carriers in therapy of osteomyelitis caused by Van-sensitive Staphylococcus strains.

The effect of Vancomycin degradation products in the topical treatment of osteomyelitis.

BACKGROUND The topical application of Vancomycin is increasingly being used in orthopedics because of the development of methicillin resistant bacteria. Consequently, resistance to Vancomycin has recently been on the rise. One possible explanation for this phenomenon could be the thermal degradation of Vancomycin to antibacterially inactive crystalline degradation products (CDP-1s). The aim of our in vitro experiment was to compare the creation and elution characteristics of CDP-1s and the active form of Vancomycin (factor B) released from bone grafts. METHODS CDP-1s and the factor B released from bone grafts into the buffer solution were measured using the high-performance liquid chromatography method at progressive intervals. RESULTS The factor B was released from bone grafts at the highest levels, typically on the first day (618.8 mg/L). CDP-1 levels kept increasing until the end of measurement on day 15, when the concentration of CDP-1s (1280.7 mg/L) was much higher compared to that of factor B (217.5 mg/L). CONCLUSIONS We confirmed the tendency of Vancomycin to convert to antimicrobially ineffective CDP-1s. Although Vancomycin is decomposed into crystalline degradation products, its active forms are released from bone grafts in sufficient concentration for more than two keks (Tab. 3, Fig. 1, Ref. 15).

Study of the variability of scapular inclination and the glenoid version - considerations for preoperative planning: clinical-radiological study

BackgroundPreoperative planning with the aid of imaging methods is a principal factor in successful surgery on the shoulder. This work aims to evaluate the variability of glenoid version, spiralling twist and scapular inclination in relation to the frontal axis. Studies focusing on measuring the variability of scapular inclination in the standardised rest position are lacking in the literature.MethodsWe evaluated 104 CT scans of the shoulder. We measured the glenoid version with respect to the scapular axis at three levels. We measured the scapular inclination angle in relation to the sagittal plane and we determined scapular inclination in relation to the frontal axis. Statistical evaluation was performed using the marginal linear model and parameters were estimated using the generalised least squares method, which enables the dependency of measurements performed on the same subject to be taken into consideration.ResultsThe highest values of retroversion are attained by the glenoid in the cranial section (average -9.96°, range -29.7 to +13.2°). Proof of the spiralling twist is the decline in retroversion at the centre of the glenoid (average -2.09°, range -16.7 to +11.6°).Retroversion decreases further in the inferior direction (average -0.5°, range -20.9 to +17.5°). The average thoracoscapular angle is 45.46°, ranging from 13.1 to 69.0°. The average scapular inclination in relation to the frontal plane is 44.54°, ranging from 21.0 to76.9°.ConclusionsDuring preoperative planning, the surgeon should take into consideration not only the glenoid version in relation to the scapular axis, but also the value of the scapular inclination so as to eliminate possible surgical errors, optimise prosthesis implantation and thus decrease the risk of functional restrictions of the joint.Clinical trial registrationEthics Committee for Multi-Centric Clinical Trials (EK-554/14,29thApril 2014).

The change of first metatarsal head articular surface position after Lapidus arthrodesis

BackgroundThe Lapidus procedure has been used for hallux valgus deformity correction since 1931. In some cases, the arthrodesis results in an unfavourable lateral inclination of first metatarsal head articular surface. The objective of our study was to evaluate the change of orientation of this articular surface in relation to the second metatarsal axis by comparing pre- and postoperative radiographs. The secondary target was to evaluate possible benefits of combination of Lapidus and Akin procedures in the reduction of hallux valgus deformity.MethodsWe evaluated 449 pre- and postoperative radiographs of 134 operations from 2010 to 2015. Routinely used angle measurements were performed on all X-rays. A sum of tangential angle to the second axis and distal articular set angle values was chosen as the best indicator for the deformity correction success.ResultsThe mean value of these angles total was 5.2° ±9.3° before and 14.2° ±7.8° after the operation. In the group of patients, where the additional Akin osteotomy was used, the mean value was 5.3° ±8.4° before and 6.9° ±10.2° after the surgery. The mean difference in values between the two groups (with and without Akin procedure) was 7.3° of extra correction in favour of the group with the Akin osteotomy.ConclusionsThe mean worsening of the tangential angle after Lapidus operation was 6.1° ±6.9°, which counts for significant deterioration after a surgery. The Akin osteotomy was found to be a valuable addition to the Lapidus arthrodesis, which improves the position of articular surfaces in first metatarsophalangeal joint.

Mathematical modelling for the comparison of plate and intramedullary osteosynthesis stability in intraarticular distal radius fractures.

BACKGROUND A comparison between plate and intramedullary osteosynthesis techniques in terms of the biomechanical stability of distal radius fracture fixation. METHODS Mathematical modelling was used to simulate distal radius fractures, type C1 and type C2, and to compare the stability of osteosynthesis in both techniques under several wrist joint load conditions: axial compressive loading of the radius, bending loads in volar and dorsal flexion and radial and ulnar deviation, and axial torsional loading of the forearm. RESULTS For both type C1 and type C2 fractures, the stability of intramedullary osteosynthesis was comparable with plate osteosynthesis in dorsal flexion. Plate osteosynthesis proved to be more stable only in ulnar deviation. The intramedullary X-screw technique provided more stability when loads were applied in volar flexion, radial deviation, pronation and supination, and in axial loading of the radius. CONCLUSIONS The result of mathematical simulations was comparable for both types of fracture. It showed a higher stability of intramedullary osteosynthesis. Although when lower force intensity was applied, both techniques were comparable (Fig. 8, Ref. 16).