Primary cementless stems in septic hip revision: Indications and results

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Qualitative Alpha-defensin Versus The Main Available Tests For The Diagnosis Of Periprosthetic Joint Infection: Best Predictor Test?

Introduction: Biomarkers such as \u3b1-defensin demonstrated to be a potentially useful option in periprosthetic joint infection (PJI) diagnosis. Recently, a new point-of-care test for \u3b1-defensin level detection in synovial fluid has been commercialized in Europe. The aim of this study is to compare the \u3b1-defensin test (SynovasureTM) diagnostic ability with the main available clinical tests for periprosthetic joint infection diagnosis in a practical clinical setting of a Bone Infection Unit. Methods: Between 2015 and 2017, 146 patients with suspected chronic PJI were screened with SynovasureTM. Seventy-three of these met the Musculoskeletal Infection Society (MSIS) criteria and were included in the analysis. According to MSIS criteria, 40 patients (54.7%) were classified as infected and 33 (45.3%) as not infected. The results obtained with SynovasureTM were recorded and compared with standard diagnostic methods for PJI diagnosis. Results: SynovasureTM showed a sensitivity of 85.0 % (95% CI 70.2 to 94.3) and a specificity of 96.9 % (95% CI 83.8 to 99.9) for PJI detection. The positive likelihood ratio of SynovasureTM was 27.2 (95% CI 3.9 to 188.1) and the negative likelihood ratio was 0.2 (95% CI 0.1 to 0.3). The diagnostic odds ratio was 181.3 (95% CI 20.7 to 1590.4). SynovasureTM demonstrated a statistical significant difference when compared to Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein (CRP) specificity (at least one positive test) and preoperative culture sensitivity (1 positive culture). Conclusion: Our findings show that SynovasureTM sensitivity is lower than quantitative \u3b1-D test, but when compared to the main available tests shows a good specificity and the highest DOR. On the SF it is the easier test to do, due to the fact that it needs a minimal amount of SF and it is not limited by blood contamination or antibiotic use. Whereas there is no single standalone test, SynovasureTM should be considered a reliable additional test for periprosthetic joint infection diagnosis in everyday clinical practice

Intravenous methylprednisolone pulses in hospitalised patients with severe COVID-19 pneumonia, A double-blind, randomised, placebo-controlled trial

Rationale: Pulse glucocorticoid therapy is used in hyperinflammation related to coronavirus 2019 (COVID-19). We evaluated the efficacy and safety of pulse intravenous methylprednisolone in addition to standard treatment in COVID-19 pneumonia. Methods: In this multicenter, randomised, double-blind, placebo-controlled trial, 304 hospitalised patients with Covid-19 pneumonia were randomised to receive 1 g of methylprednisolone intravenously for 3 consecutive days or placebo in addition to standard dexamethasone. The primary outcome was the duration of the patient hospitalisation, calculated as the time interval between randomisation and hospital discharge without the need of supplementary oxygen. The key secondary outcomes were survival free from invasive ventilation with orotracheal intubation and overall survival. Results: Overall, 112 of 151 (75.4%) patients in the pulse methylprednisolone arm and 111 of 150 (75.2%) in the placebo arm were discharged from hospital without oxygen within 30 days from randomisation. Median time to discharge was similar in both groups [15 days (95% confidence interval (CI), 13.0 to 17.0) and 16 days (95%CI, 13.8 to 18.2); hazard ratio (HR), 0.92; 95% CI 0.71-1.20; p=0.528]. No significant differences between pulse methylprednisolone and placebo arms were observed in terms of admission to Intensive Care Unit with orotracheal intubation or death (20.0% versus 16.1%; HR, 1.26; 95%CI, 0.74-2.16; p=0.176), or overall mortality (10.0% versus 12.2%; HR, 0.83; 95%CI, 0.42-1.64; p=0.584). Serious adverse events occurred with similar frequency in the two groups. Conclusions: Methylprenisolone pulse therapy added to dexamethasone was not of benefit in patients with COVID-19 pneumonia. Message of the study: Pulse glucocorticoid therapy is used for severe and/or life threatening immuno-inflammatory diseases. The addition of pulse glucocorticoid therapy to the standard low dose of dexamethasone scheme was not of benefit in patients with COVID-19 pneumonia

Use of porous custom-made cones for meta-diaphyseal bone defects reconstruction in knee revision surgery: a clinical and biomechanical analysis.

Although the practice of metaphyseal reconstruction has obtained successful clinical and radiological results in revision total knee surgery, off-the-shelf devices aren't an effective solution for all patients as they do not cover the full range of clinical possibilities. For this reason, during severe knee revisions, custom-made porous titanium cementless metaphyseal cones are nowadays employed as alternative to traditional surgeries. The aim of this study is to understand the benefits gained by the use of the custom-made cones against the performance of more traditional techniques, such as the use of cemented or cementless stems. Thus, a retrospective study on eleven patients and a biomechanical finite element analysis (FEA) was developed, based upon three clinical cases of the clinical analyzed cohort.info:eu-repo/semantics/publishe

Two-stage revision for periprosthetic joint infection in unicompartmental knee arthroplasty: clinical and radiological results

Introduction Unicompartmental knee arthroplasty (UKA) has an infection rate of 0.1-0.8%. Despite the wide amount of literature about septic total knee arthroplasty management, few data are available for UKA infection treatment. The aim is to present the clinical and radiological outcomes along with complication rates of a series of septic UKA treated with two-stage exchange. Methods We retrospectively reviewed 16 patient treated with staged UKA revision for infection between June 2015 and September 2019 in a single bone infection unit. The main demographic and surgical data were recorded. Clinical scores (VAS, KSS, OKS, postoperative ROM), radiological parameters (osseointegration, loosening and radiolucencies) and complications were reported. The mean follow-up was 33.5 +/- 6.9 months. Results Mean age at surgery was 68.5 +/- 9.1. All but two were medial UKA. The mean number of previous surgeries was 2.9 +/- 1.9. The mean ROM, VAS, KSS and OKS of the entire population improved significantly (p < 0.01). Radiological analysis did not show any migration or implant loosening. Ten constrained condylar and six posterior stabilized prosthesis were finally implanted. One intraoperative pathogen isolation was recorded and managed with suppressive therapy and good final outcome. The implant survivorship free from infection was 100% at the final follow-up. The overall survival rate for any reason of revision was 100% Conclusion According to our results, staged revision represents a reliable ad effective option in delayed and late UKA infections. This technique provides optimal clinical and radiological results with acceptable complication rates. To the best of our knowledge, this represent the widest case series on infected UKA managed with two-stage exchange

Acetabular custom-made implants for severe acetabular bone defect in revision total hip arthroplasty: a systematic review of the literature

Purpose The management of acetabular bone loss is a challenging problem in revision total hip arthroplasty (rTHA). The aim of this systematic review is to summarize and critically analyze indications, complications, clinical and radiological outcomes of custom-made acetabular components in rTHA. Methods A systematic review of English literature was performed on Medline. Retrospective or prospective studies with minimum 2 years of follow-up (FU) were included. The PRISMA 2009 flowchart and checklist were considered to edit the review. Rates of intra- or post-operative complications, aseptic loosening (AL), periprosthetic joint infection (PJI), reoperations and re-revisions rates were extrapolated. Results 18 articles with a level of evidence of IV were included. Six hundred and thirty-four acetabular custom components (627 patients) with a mean FU of 58.6 +/- 29.8 months were analyzed. The studies showed good clinical and functional outcomes. Custom-made acetabular components allowed a stable fixation with 94.0 +/- 5.0% survival rate. The estimated rate of re-operations and re-revisions were 19.3 +/- 17.3% and 5.2 +/- 4.7%, respectively. The incidence of PJI was 4.0 +/- 3.9%. Conclusions The acetabular custom-made implants represent a reliable solution for pelvic discontinuity and particular cases of bone loss classified as Paprosky Type IIIA-B or type III-IV according to American Academy of Orthopaedic Surgeons system where the feature of the defect cannot be handled with standard implants. This strategy allows to fit the implant to the residual host bone, bypassing the bony deficiency and restoring hip biomechanics. Satisfactory clinical and radiological outcomes at mid-term follow-up are reported in literature

The Use of Tantalum Metaphyseal Cones for the Management of Severe Bone Defects in Septic Knee Revision

Background: Femoral and tibial massive bone defects are common findings in septic total knee revision and pose considerable challenges for the orthopedic surgeon. The aim of this study was to report the midterm clinical and radiographic outcomes with the use of tantalum cones for the management of massive bone defects after 2-stage knee revision. Methods: We retrospectively reviewed the medical records of 60 patients (mean age, 67.9 \ub1 8.8 years) treated with 94 tantalum cones associated with constrained or semiconstrained knee for massive bone loss (mean follow-up, 43.5 \ub1 17.4 months). In all cases, the indication was a staged revision for periprosthetic knee infection. Functional scores, radiographic outcomes, and implant survivorship were analyzed. Results: The mean Knee Society Score and Oxford Knee Score improved from 44.1 \ub1 7.4 and 19.2 \ub1 4.1 to 85.4 \ub1 5.6 and 38.4 \ub1 3.9 (P <.01), respectively. The mean flexion increased from 60.6\ub0 \ub1 15.5\ub0 to 96.8\ub0 \ub1 10.9\ub0 at the last evaluation (P <.01). The mean improvement in flexion contracture was 6.2 \ub1 8.0 (P <.01). Two failures (3.3%) due to periprosthetic knee infection recurrence were observed, but no cone-related mechanical failures were reported. The cone-related survival rate was 97.8%. Conclusion: Excellent clinical and radiographic midterm outcomes were achieved with a low complication rate. Tantalum cones may be considered a safe and effective option in the management of massive bone defects also in septic knee revision surgery