Richard F. Kyle

Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections.

BACKGROUND The clinical presentation of an infection at the site of a total knee arthroplasty can be used as a guide to treatment, including the decision as to whether the prosthesis should be retained or removed. We reviewed the results of treatment of infection after total knee arthroplasty to evaluate the effectiveness of four treatment protocols based on the clinical setting of the infection. METHODS We retrospectively evaluated the results of treatment of eighty-one infections in seventy-six consecutive patients who either had an infection after a total knee arthroplasty or had multiple positive intraoperative cultures of specimens of periprosthetic tissue obtained during a revision total knee arthroplasty performed because of presumed aseptic loosening. The patients were managed according to one of four protocols. Five infections in five patients who had positive intraoperative cultures were treated with antibiotic therapy alone. Twenty-three early postoperative infections in twenty-one patients were treated with débridement, antibiotic therapy, and retention of the prosthesis. Twenty-nine late chronic infections in twenty-eight patients were treated with a delayed-exchange arthroplasty after a course of antibiotics. Seven acute hematogenous infections in six patients were treated with débridement, antibiotic therapy, and retention of the prosthesis. Seventeen infections in seventeen patients were not treated according to one of the four protocols. Sixteen late chronic infections were treated either with an arthrodesis (five infections) or with débridement, antibiotic therapy, and retention of the prosthesis (eleven infections). One acute hematogenous infection was treated with resection arthroplasty because of life-threatening sepsis. RESULTS The mean duration of follow-up was 4.0 years (range, 0.3 to 14.0 years). Eleven patients who had an arthrodesis, a resection arthroplasty, or an above-the-knee amputation after less than two years of follow-up were included in the study as individuals who had a failure of treatment. In the group of patients who were managed according to protocol, the initial course of treatment was successful for all five infections that were diagnosed on the basis of positive intraoperative cultures, five of the ten deep early infections, all thirteen superficial early infections, twenty-four of the twenty-nine late chronic infections, and five of the seven acute hematogenous infections. Only one of eleven prostheses in patients who had a late chronic infection that was not treated according to protocol was successfully retained after débridement. CONCLUSIONS Our treatment protocols, which were based on the clinical setting of the infection, were successful for most patients. A major factor associated with treatment failure was a compromised immune status. Bone loss and necrosis of the soft tissues around the joint also complicated the treatment of these infections.

Analysis of six hundred and twenty-two intertrochanteric hip fractures.

Of 622 intertrochanteric fractures, 57% were stable (Types I and II). Twenty-eight per cent were Type III, and 15% were Type IV (the unstable types). The 150-degree telescoping Massie nail proved superior to the fixed 135-degree Jewett nail (particularly for unstable fractures) because it allowed a controlled impaction of the fracture fragments to a stable position. In about one-third of the fractures, some medial displacement occurred. With anatomical reduction and the use of the Massie or ASIF nails, we achieved a decrease in the morbidity and mortality and 96% satisfactory results. Our prospective study was compared with a retrospective study in which other devices were used. Early ambulation and weight-bearing also was a major contributing factor to the improved results in the prospective study. Intertrochanteric hip fractures that are unstable can be fixed with a collapsible nail, and that treatment appears to give as good or better results than the displacement method of Dimon and Hughston or Sarmiento.

A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft.

OBJECTIVES To determine if there are differences in healing, complications, or number of procedures required to obtain union among open and closed tibia fractures treated with intramedullary (IM) nails inserted with and without reaming. DESIGN Prospective, surgeon-randomized comparative study. SETTING Level One trauma center. PATIENTS Ninety-four consecutive patients with unstable closed and open (excluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997. INTERVENTION Interlocked IM nail insertion with and without medullary canal reaming. MAIN OUTCOME MEASURES Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union. RESULTS For open fractures, there were no significant differences in the time to union or number of additional procedures performed to obtain union in patients with reamed nail insertion compared with those without reamed insertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary procedures were needed to obtain union after unreamed nail insertion for the treatment of closed tibia fractures, but the difference was not statistically significant given the limited power of our study (p = 0.155). Broken screws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncompliant with weight-bearing restrictions. There were no differences in rates of infection or compartment syndrome. CONCLUSION Our findings support the use of reamed insertion of IM nails for the treatment of closed tibia fractures, which led to earlier time to union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.

Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: Preparing for an epidemic

The demand for health-care services in general, and musculoskeletal care in particular, is expected to increase substantially in the United States because of the growth of the population, aging of the population, public expectations, economic growth, investment in health-care interventions, and improved diagnosis and treatment. The impact of an aging population is demonstrated by the fact that, in 2000, the eleven most costly medical conditions in the United States were far more prevalent among the elderly, and the population of elderly Americans is increasing. It is not clear that the future supply of physicians will be sufficient to meet the increasing demand for health care. The supply of American physicians is limited by the aging and retirement of current physicians, medical school graduation class size of allopathic medical doctors and osteopathic physicians, and United States immigration policies, which limit the number of physicians entering the country. Furthermore, among active physicians, the “effective physician supply” is limited by gender and generational differences, lifestyle choices, changing practice patterns, and variability in physician productivity. At current physician production levels, the ratio of physicians to population will peak between 2015 and 20201. Between 2000 and 2020, the demand for orthopaedic services in this country will increase by 23% while the supply of orthopaedic surgeons will increase by only 2% during the same interval2. During the next few decades, the demand for total joint arthroplasties in the United States may not be met because of an inadequate supply of total joint arthroplasty surgeons. This hypothesis or concern is based on data and trends associated with the prevalence of total joint arthroplasty, projected volumes of total joint arthroplasty, workforce trends in total joint arthroplasty, and reimbursement for total joint arthroplasty. The purposes of this paper are to evaluate the validity of this …

Fractures of the proximal part of the femur.

The orthopaedic surgeon has a multitude of internal fixation devices and techniques available for use in the treatment of subtrochanteric fractures of the proximal femur. The successful use of second-generation locking nails is technically demanding. Close attention to positioning of the patient, reduction of the fracture, placement of the guide-wire, and insertion of the nail and of the proximal and distal locking screws is mandatory. The newer, high-strength hip-screws allow good fixation of a fracture that extends into the piriformis fossa. If medial comminution is present, this technique is best performed in conjunction with indirect reduction and bone-grafting. With proper technique, these devices allow the surgeon to manage predictably a complex subtrochanteric fracture that previously had to be treated with traction or extensive dissection and with (frequently inadequate) internal fixation.

Diagnosis and Management of Infection After Total Knee Arthroplasty

The key to successful management of an infection at the site of a total knee arthroplasty is an early and accurate diagnosis that allows prompt treatment. Therefore, it is critical that every patient with pain at the site of a total knee arthroplasty is assessed for the presence of infection1. The usual presentation is characterized by constant pain, warmth, and effusion. Erythema is unusual. It is important to elicit the history of the perioperative course that followed the primary total knee replacement: Did the original wound heal without delay? Was there any postoperative drainage? A complete history ( Table I), physical examination, plain radiographs, and other diagnostic studies discussed below are critical to confirm the diagnosis of infection and to rule out other causes of knee pain2. View this table: TABLE I: Risk Factors for Infection Following Total Knee Arthroplasty Aspiration of the affected knee should be among the first diagnostic tests performed3-5. If the first aspirate is negative but a suspicion of infection remains, then at least two additional aspirations should be performed. Any current antibiotic therapy should be sdiscontinued for a minimum of ten days, and the aspiration should then be repeated. The aspirate should be sent for aerobic, anaerobic, and fungal cultures, and a white blood-cell count with differential should be performed. Blood tests should include determination of the erythrocyte sedimentation rate and the C-reactive protein level. The results of aspiration of the knee must be correlated with the results of the physical examination and radiographs for complete assessment of the possibility of infection6. Radionucleotide studies, particularly bisphosphonate scans in conjunction with indium-labeled leukocyte scans, may contribute to a proper diagnosis. A normal radionucleotide scan suggests that loosening or infection is not the likely cause of pain. It must be remembered, however, …

Periprosthetic Fractures of the Femur

Periprosthetic fractures of the femur represent a heterogeneous and challenging problem for the orthopedic surgeon. The incidence of these fractures is dramatically increasing, as there are more and more patients with aging total joint replacements. The fractures may occur as the result of a traumatic event, but more often are the result of minor trauma spontaneous fracture, and they are frequently associated with preexisting, sometimes neglected, problems with the associated joint replacement.

Norian Srs Cement Augmentation in Hip Fracture Treatment: Laboratory and Initial Clinical Results

Bone quality, initial fracture displacement, severity of fracture comminution, accuracy of fracture reduction, and the placement of the internal fixation device are important factors that affect fixation stability. New high strength cements that are susceptible to remodeling and replacement for fracture fixation may lead to improved clinical outcome in the treatment of hip fractures. Norian SRS is an injectable, fast setting cement that cures in vivo to form an osteoconductive carbonated apatite of high compressive strength (55 MPa) with chemical and physical characteristics similar to the mineral phase of bone. It can be used as a space filling internal fixation device to facilitate the geometric reconstruction, load transfer, and healing of bone with defects and/or fractures in regions of cancellous bone. Furthermore, this cement can improve the mechanical holding strength of conventional fixation devices. Use of this material potentially could improve fracture stability, retain anatomy during fracture healing and improve hip function, thus achieving better clinical outcomes. In vivo animal studies have shown the materials biocompatibility, and cadaveric studies have shown the biomechanical advantage of its use in hip fractures. Initial clinical experience (in 52 femoral neck fractures and 39 intertrochanteric fractures) showed the potential clinical use of this innovative cement in the treatment of hip fractures.

Comparative Analysis of Ankle Arthroplasty versus Ankle Arthrodesis

In a retrospective study of 41 patients with total ankle arthroplasty (25 patients) and ankle arthrodesis (18 patients), the mean follow-up period was 3.8 years for total ankle arthroplasties and 3.3 for ankle arthrodeses. Sixteen of the 23 ankle arthroplasty patients, and 17 of the 18 arthrodesis patients had good or excellent results. Total ankle arthroplasty was successful in patients with rheumatoid arthritis, but not posttraumatic arthrosis. Total ankle arthroplasty is indicated in rheumatoid patients with severe ankle involvement who have not responded to medical management. It also may be used in the elderly or debilitated patients who will place minimal stress on the ankle. The elderly may not tolerate the prolonged immobilization or repeated operations that fusion may require. Total ankle arthroplasty should not be used in young patients with posttraumatic arthrosis.

Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia

Twenty-eight tibial fractures, initially treated with nonreamed interlocking nails, were exchanged to reamed intramedullary nails to promote union. Initially, there were 8 closed fractures with compartment syndromes; 5 Type 2 open fractures; 6 Type 3 A injuries; and 6 Type 3B injuries. Exchange nailing was performed if followup radiographs did not show callus formation between 3 and 5 months after injury. Originally, 16 of the 28 nailings were statistically locked. Twenty-five of 27 fractures united after exchange nailing. In 2 patients with bone loss, additional bone grafting was required. Infection developed in 3 patients after exchange nailing (11%). Exchange nailing is a useful method to promote union of tibial fractures when slow consolidation occurs after initial treatment with a nonreamed nail. This method should be combined with autogenous bone grafting in patients with bone loss. The procedure is safe and effective in closed and minor open fractures; however, caution should be exercised in patients with prior Grade 3B open fractures because of the risk of infection.