Periprosthetic Infections after Total Hip and Knee Arthroplasty – A Review

Periprosthetic joint infections (PJI) in orthopedic surgery are considered to be very serious and dangerous complications of total joint arthroplasty. PJI becomes a long-lasting medical problem and a heavy burden on patient and his family. Patients with such a complication are a signifi cant fi nancial burden for the health care system. Recognizing this issue, investing in scientifi c research and simultaneously developing technologies in medicine are efforts taken to increase successfulness in preventing and treating PJI. Each year the number of total joint arthroplasties increases which entails a rise in the number of complications among which infections are the leading ones. Sometimes, in the worst case scenarios, infections can endanger patients’ lives. New procedural algorithms and new diagnostic possibilities help us make accurate and early diagnoses of postoperative PJI with a great degree of certainty. These diagnostic methods include laboratory tests, imaging, histopathology and microbiological analyses. Treatment options depend on many factors which include the onset of symptoms, patients’ general physical condition and type of pathogen. The approach to treating PJI is complex and it requires a multidisciplinary approach in order to ensure the most successful treatment possible. For adequate and successful treatment we need to take into account antibiotic therapy, one-stage or two-stage revision, Girdlestone operation, athrodesis and amputation. In this review we will try to sum up all relevant fi ndings and suggest further steps in management of PJI

COMPUTER REPRESENTATION OF OSTEOSYNTHESIS STABILITY IN LOCKING PLATES USED FOR THE TREATMENT OF OSTEOPOROTIC PROXIMAL HUMERUS FRACTURES

Background: Proximal humerus fractures are represented as 4-5% of all fractures, with incidence notably growing with age. Since surgical internal fixation in treatment of proximal humeral fractures is used, fractures of osteoporotic bone and choice of plate for their osteosynthesis represent particular problem. The aim of the study was to test two locking plates: Philos plate with locking screws with determinated direction, and Arthrex plate with poliaxial locking screws, using the finite element method. Subjects and methods: This study used version 6.10 of Abaqus FEA software package for simulation and fine element analysis of Philos and Artrex plates attached to the osteotomy models of proximal humerus with fracture gap at 0°, 10° and 20° in four types of static load: abduction, adduction, axial compression and flexion. Simulation results of loads in abduction, adduction, axial loads and flexion, were described with the total bone displacement (U) and maximum bone displacement in the fracture gap (Uf ). Results: When examining the Philos plate in axial load on the bone with fracture gap angle from 0°, 10° and 20° no significant differences between the results for the displacements were observed. Therefore, results for other loads are related to total displacements of the bone only at the angle of 0°. Given that the results of the total bone displacement and maximum bone displacement in the fracture gap with Artrex plate were mostly higher, for comparison with the results of bone displacement in Philos plate it was taken that total bone displacement and maximum displacement in the fracture gap in Artrex plate represent 100% of the total displacement. Philos plate showed 60.71% for abduction, 76.07% for adduction, 102.24% for axial loads and 79.59% for flexion of total bone displacement in Artrex plate, and 60.48% for abduction, 76.07% for adduction, 96.05% for axial load and 79.96% for flexion of maximum displacement in the fracture gap in Artrex plate. Conclusions: Osteosynthesis for osteoporotic fractures of proximal humerus with Philos plate in computer simulation proved to be more stable than with Arthrex plate

THE RESULTS OF INTERNAL FIXATION OF PROXIMAL HUMERAL OSTEOPOROTIC FRACTURES WITH PHILOS LOCKING PLATE

Background: In the last fifty years since plate and screw osteosynthesis has been implemented in fracture treatment, osteosporotic bone fractures were observed as a special problem. Due to special histologic, anatomic, physical and biomehanic properties of osteoporotic changed bone the laws of biomechanics suggest that stable osteosynthesis for osteoporotic bone is necessary to increase the contact surface of metallic implants and bone and the stability of the screw-plate-bone compound. There are numerous surgical techniques and methods for treatment of osteoporotic proximal humeral fractures. Every surgical procedure has to establish anatomical reduction and stable fixation that will enable early mobilisation. Subjects and methods: The aim of this study was to present results of internal fixation of proximal humeral osteoporotic fractures with PHILOS locking plate. Between 2007 and 2012, a total of 67 patients older than 65 years with closed proximal humerus fractures underwent surgical treatment with PHILOS plate system (Synthes, Switzerland). 42 patients were operated with deltopectoral approach and 25 with deltoid split approach. After a mean follow up period of 14.68 (6-28) months functional and radiologic results were assessed. Results: We noted 9 postoperative complications related to surgical technique (1 intraarticular screw placement, 1 displacement in major tuberculum fragment, 1 displacement in major tuberculum fragment along with oblique placement of the plate, 2 cases of inadequate reduction, 1 case of humeral head avascular necrosis, varus humeral head fixation in 3 cases). None of the patients developed superficial or deep surgical infection. There was no nonunions. In the final evaluation, the Constant shoulder score was 91.75 (72-100). Conclusions: In this study PHILOS locking plate showed good applicability, respecting bone biologic properties because of negligible interference with blood supply of the humeral head. There was no requirement to shape the plate enabling stabilization at constant angles as clear benefit of this plate. All that enables early mobilisation, and no implant insufficiency resulting in satisfactory treatment results and high Constant shoulder scores

Osteochondritis Dissecans of the Medial and Lateral Femoral Condyles affecting Adult Knee

We report the first case of osteochondritis dissecans (OCD) affecting a large area of lateral and medial femoral condyles with adult-onset in the same knee of the 22-year old professional athlete with respect to result of applied therapeutic procedure. After a clinical examination, radiograph and magnetic resonance imaging showed a huge bicondylar OCD. Through arthrotomy, the osteochondral fragment was fixed with biodegradable pins combined with two threaded 4 mm cobalt-chrome cancellous screws. By using this surgical fixation procedure, osteochondral fragments healed completely, which is evidenced artroscopically one year after a new trauma episode which resulted in the lateral meniscus reinjury. According to our knowledge this is the first reported case of bicondylar OCD affecting adult knee. In the rare case of such a large osteochondral defect, when fixation with biodegradable pins could be insufficient, a combination with cancellous screws can bring good results, even in professional athletes

Treatment of Hardware Infection after Osteosynthesis of Lower Leg using Negative Pressure Wound Therapy and Transforming Powder Dressing

Fractures of the distal part of the lower leg are more common in everyday practice and traumatology. In young and active patients these injuries are mainly caused by high energy trauma. They are treated with external fi xator in fi rst step, and in second step, after sanation of the soft tissue, with open reduction and internal fi xation (ORIF). It is very safe and effective method of treatment. Treatment of the infections that occur in the early postoperative period after open reduction and internal fi xation represents a great problem and challenge for surgeons. It is widely accepted that the presence of deep infection can´t be cured in the presence of hardware. However, removal of hardware in the presence of unhealed fractures signifi cantly complicates sanation of infection and fracture itself. We have decided to present a 35-years-old patient with a hardware infection with present chronic wound with hardware exposed eight months after the fi rst operation and six months after second operation. The wound measured one centimeter in diameter with cell detritus and bad granulations tissue inside the wound. Hardwre was exposed in the depth of the wound.The secretion was minimal. Negative Pressure Wound Therapy (NPWT) was applicated after debridemet and lavage performed in ambulatory conditions. The starting therapy was continuously –125 mm Hg of vacuum. After fi ve days of NPWT the defect was partially fi lled with granulation tissue. For another fi ve days we continue with NPWT with the same values of –125 mm Hg pressure but in the intermitent mode. After that period we used transforming powder dressing for covering and protection of the wound with was fi lled with granulation tissue. Five days later, wound was completely healed with epithelisation. After four months of patient follow-up, we found the wound is completely repaired. The patient denies pain and has continued orderly fl ow of fracture healing, with no signs of infection

Computer representation of osteosynthesis stability in locking plates used for the treatment of osteoporotic proximal humerus fractures

Background: Proximal humerus fractures are represented as 4-5% of all fractures, with incidence notably growing with age. Since surgical internal fixation in treatment of proximal humeral fractures is used, fractures of osteoporotic bone and choice of plate for their osteosynthesis represent particular problem. The aim of the study was to test two locking plates: Philos plate with locking screws with determinated direction, and Arthrex plate with poliaxial locking screws, using the finite element method. Subjects and methods: This study used version 6.10 of Abaqus FEA software package for simulation and fine element analysis of Philos and Artrex plates attached to the osteotomy models of proximal humerus with fracture gap at 0°, 10° and 20° in four types of static load: abduction, adduction, axial compression and flexion. Simulation results of loads in abduction, adduction, axial loads and flexion, were described with the total bone displacement (U) and maximum bone displacement in the fracture gap (Uf ). Results: When examining the Philos plate in axial load on the bone with fracture gap angle from 0°, 10° and 20° no significant differences between the results for the displacements were observed. Therefore, results for other loads are related to total displacements of the bone only at the angle of 0°. Given that the results of the total bone displacement and maximum bone displacement in the fracture gap with Artrex plate were mostly higher, for comparison with the results of bone displacement in Philos plate it was taken that total bone displacement and maximum displacement in the fracture gap in Artrex plate represent 100% of the total displacement. Philos plate showed 60.71% for abduction, 76.07% for adduction, 102.24% for axial loads and 79.59% for flexion of total bone displacement in Artrex plate, and 60.48% for abduction, 76.07% for adduction, 96.05% for axial load and 79.96% for flexion of maximum displacement in the fracture gap in Artrex plate. Conclusions: Osteosynthesis for osteoporotic fractures of proximal humerus with Philos plate in computer simulation proved to be more stable than with Arthrex plate

THE RESULTS OF INTERNAL FIXATION OF PROXIMAL HUMERAL OSTEOPOROTIC FRACTURES WITH PHILOS LOCKING PLATE

Background: In the last fifty years since plate and screw osteosynthesis has been implemented in fracture treatment, osteosporotic bone fractures were observed as a special problem. Due to special histologic, anatomic, physical and biomehanic properties of osteoporotic changed bone the laws of biomechanics suggest that stable osteosynthesis for osteoporotic bone is necessary to increase the contact surface of metallic implants and bone and the stability of the screw-plate-bone compound. There are numerous surgical techniques and methods for treatment of osteoporotic proximal humeral fractures. Every surgical procedure has to establish anatomical reduction and stable fixation that will enable early mobilisation. Subjects and methods: The aim of this study was to present results of internal fixation of proximal humeral osteoporotic fractures with PHILOS locking plate. Between 2007 and 2012, a total of 67 patients older than 65 years with closed proximal humerus fractures underwent surgical treatment with PHILOS plate system (Synthes, Switzerland). 42 patients were operated with deltopectoral approach and 25 with deltoid split approach. After a mean follow up period of 14.68 (6-28) months functional and radiologic results were assessed. Results: We noted 9 postoperative complications related to surgical technique (1 intraarticular screw placement, 1 displacement in major tuberculum fragment, 1 displacement in major tuberculum fragment along with oblique placement of the plate, 2 cases of inadequate reduction, 1 case of humeral head avascular necrosis, varus humeral head fixation in 3 cases). None of the patients developed superficial or deep surgical infection. There was no nonunions. In the final evaluation, the Constant shoulder score was 91.75 (72-100). Conclusions: In this study PHILOS locking plate showed good applicability, respecting bone biologic properties because of negligible interference with blood supply of the humeral head. There was no requirement to shape the plate enabling stabilization at constant angles as clear benefit of this plate. All that enables early mobilisation, and no implant insufficiency resulting in satisfactory treatment results and high Constant shoulder scores

Osteochondritis Dissecans of the Medial and Lateral Femoral Condyles affecting Adult Knee

We report the first case of osteochondritis dissecans (OCD) affecting a large area of lateral and medial femoral condyles with adult-onset in the same knee of the 22-year old professional athlete with respect to result of applied therapeutic procedure. After a clinical examination, radiograph and magnetic resonance imaging showed a huge bicondylar OCD. Through arthrotomy, the osteochondral fragment was fixed with biodegradable pins combined with two threaded 4 mm cobalt-chrome cancellous screws. By using this surgical fixation procedure, osteochondral fragments healed completely, which is evidenced artroscopically one year after a new trauma episode which resulted in the lateral meniscus reinjury. According to our knowledge this is the first reported case of bicondylar OCD affecting adult knee. In the rare case of such a large osteochondral defect, when fixation with biodegradable pins could be insufficient, a combination with cancellous screws can bring good results, even in professional athletes