Prosthetic joint infection: A major threat to successful total joint arthroplasty

Total joint arthroplasty (TJA) is one of the most common and reliable orthopaedic procedures that has significantly improved the quality of life of patients with degenerative joint diseases. Following the increase in the ageing population, availability of trained orthopaedic surgeons and advances in implantation procedures, demand for TJA both globally and in India is significantly increasing. Though TJA is one of the most cost-successful orthopaedic procedures, prosthetic joint infection (PJI) is one of the major complications of joint arthroplasty. Accurate diagnosis of PJI is challenging. Since total hip and knee arthroplasties comprises the majority of TJAs, this review focuses on the current understanding of incidence, risk factors, pathogenesis, causative microorganisms, diagnosis, treatment and prevention of PJI related to these two procedures.

Effects of cyclamic acid on dynamic monitoring D-Dimer and thromboembolic prophylaxis during total hip arthroplasty / 中国综合临床

Objective To study the effects of use of cyclamic acid on monitoring D-Dimer and predicting deep venous thrombosis on lower limbs during total hip arthroplasty.Methods Ninety-three cases patients who received total hip arthroplasty operations at Joint Surgery Department of the Central Hospital of Zhuzhou city and Zhuzhou Hospital Affiliated to Xiangya Medical College of Central South University from December 2015 to May 2016 were selected as subjects and randomly assigned into study group with 50 cases and control group with 43 cases.During the operations,cyclamic acid was used intravenously and locally as a routine in the study group while saline was utilized instead in the control group.The D-Dimer was dynamically monitored before operation and 1,3,5,7,9 d after the operation,and venous color ultrasonography of both lower limbs were taken 3,6,9 d after the operation to check the conformation of thrombosis.Results The total blood loss after treatment in the study group was (350.5 ± 65.2) ml,intraoperative blood loss of (129.3 ± 43.1) ml,postoperative drainage volume of (80.9± 12.6) ml,occult blood loss of (141.9± 20.6) ml,corresponding to the control group were (560.8±60.6) ml,(208.9± 57.8) ml,(150.8 ± 18.9) ml,(202.9±23.9) ml.The above indicators were lower in the study group than in the control group,the differences between the two groups were statistically significant(t =16.02,7.59,21.24,13.22,P＜0.05).There were significant differences in terms of D2-dimer level of 1,3,5 d after the operation between the study group and the control group (P＜0.05),but at 7,9 d after the operation,the difference between the two groups were not statistically significant(P＞0.05).The study group and the control group at 9 d after operation with color Doppler ultrasound examination showed that there were 1 cases of patients with calf vein thrombosis both in two groups,there was no significant difference between the two groups(2.00％ vs.2.32％,x2 =0.012,P＞ 0.05).Conclusion The proper use of cyclamic acid can reduce blood loss and will not increase the risk of thrombosis.Monitoring dynamically on D-Dimer and deep venous color ultrasonography on lower limbs is helpful for early detection of thrombosis after total hip arthroplasty.However,the use of cyclamic acid during total hip arthroplasty will affect the monitoring on D-Dimer and therefore needs to be taken seriously.

Efficacy of Long-term Effect and Repeat Intraarticular Botulinum toxin in Patients with Painful Total Joint Arthroplasty: A Retrospective Study.

Objective: Based on recent success of intra-articular (IA) Botulinum neurotoxin type A (BoNT/A; OnabotulinumtoxinA) in patients with osteoarthritis, we examined if repeat IABoNT/ A is an effective antinociceptive in patients with refractory arthroplasty pain. Methods: 11 patients with refractory chronic arthroplasty joint pain without any evidence of infection or prosthesis loosening were referred by orthopedic surgeons. After discussion of off-label use, each patient underwent IA injection of BoNT/A, repeated based on return of pain on numeric rating scale (NRS) and functional limitation on composite validated scales, Western Ontario McMaster Osteoarthritis index (WOMAC) or Shoulder Pain and Disability (SPADI). Results: 11 patients (10 men, 1 woman) with 14 painful arthroplasty joints (3 bilateral; 12 knee and 2 shoulder) underwent ≥1 IA-BoNT/A injections (8 joints injected once, one joint injected twice only, five joints injected thrice) with doses ranging 100-300 units. Mean age was 68 years (standard deviation, 12) and follow-up ranged 1-28 months. Clinically meaningful reduction of 2-units in pain severity and really meaningful reduction in pain severity (50% reduction) were reported by 6/11 patients (6/13 joints) and 3/11 patients (3/13 joints), respectively, 1 month after the first IA-BoNT/A (100-units each). Significant improvements were noted in composite functional scales (WOMAC/SPADI). Pain relief was sustained at 3-4 month follow-up and was reproducible in those who received repeat injections. No significant adverse events were seen in any patients. Conclusions: A single intra-articular injection of BoNT/A improved pain and function in patients with chronic, refractory painful knee or shoulder arthroplasty, which sustained with repeat injections. Patients, who were refractory to the first injection, did not respond to subsequent injections of higher dose of IA-BoNT/A.

Thromboprophylaxis for Deep Vein Thrombosis and Pulmonary Embolism after Total Joint Arthroplasty in a Low Incidence Population

Postoperative venous thromboembolism is one of the most serious complications following total joint arthroplasty. Pharmacological and mechanical prophylaxis methods are used to reduce the risk of postoperative symptomatic deep vein thrombosis and pulmonary embolism. Use of pharmacological prophylaxis requires a fine balance between the efficacy of the drug in preventing deep vein thrombosis and the adverse effects associated with the use of these drugs. In regions with a low prevalence of deep vein thrombosis such as Korea, there might be a question whether the benefits of using pharmacological prophylaxis outweigh the risks involved. The current article reviews the need for thromboprophylaxis, guidelines, problems with the guidelines, pharmacological prophylaxis use, and the current scenario of deep vein thrombosis, and discusses whether the use of pharmacological prophylaxis should be mandatory in low incidence populations.

Minocycline-induced Periarticular Black Bones in Inflamed Joints Which Underwent Arthroplastic Reconstruction

BACKGROUND: Minocycline-induced pigmentation of bone (black bone) is well described in tooth-bearing intra-oral bone, but is less known in periarticular bone in patients who have undergone total joint arthroplasty. On a retrospective basis, we investigated the short-term clinico-radiological results of total joint arthroplasties in which the patient developed minocycline-induced periarticular black bone. METHODS: We found 5 cases (0.08%), in 4 patients, of periarticular bone pigmentation revealed during total joint arthroplasties (2 hips, 2 knees, and 1 ankle) in our series of total joint surgeries (6,548 cases) over a 10-year time period in our 3 institutes. Their mean age was 56 years at surgery. All patients had received long-term minocycline treatment. Mean dosage and duration of minocycline was 160 mg/day and 2.2 years, respectively. Minocycline had been prescribed for reactive arthritis (one), rheumatoid arthritis (two) and late infection after total joint arthroplasty (two patients). Mean follow-up period was 3.4 years after the surgeries. RESULTS: All cases had black or brown pigmentation in the periarticular bones during the surgery. There was no pigmentation in the cartilage or soft tissues of the joints. The mean Japanese Orthopaedic Association (JOA) score or Japanese Society for Surgery of the Foot (JSSF) scale for rheumatoid arthritis foot and ankle joints at latest follow-up (case 1, 66; case 2, 87; case 3, 77; case 4, 77; case 5, 80) improved compared to those of pre-surgery (case 1, 47; case 2, 45; case 3, 55; case 4, 34; case 5, 55). No implant loosening was noted on radiographic examination during the follow-up period. No abnormal bone formation, bone necrosis, hemosiderin deposition, malignancy or metallic debris was found on histological examination. CONCLUSIONS: No clinico-radiological symptoms of total joint arthroplasties showed in the patients with minocycline-induced periariticular black bone in the short-term. Systemic minocycline treatment has the potential to induce significant black pigmentation of many tissues. In particular, minocycline-induced pigmentation of periarticular bone may be accelerated by inflammation due to rheumatic or pyogenic arthritis. Surgeons should recognize the risk of bone pigmentation in inflamed joints due to the systemic treatment of minocycline and explore its influence on periarticular bone and total joint arthroplasty in the long-term.

The evloution of total knee and hip joint arthroplasty

The evolution of total joint replacement is not merely of historical interest. We review the historic development of total joint arthroplasty to look at what has been selected and what has not selected in the past. For more than 30 years, total joint arthroplasty has been progressively developed to improve functional outcomes and survivorship. There has been debate regarding the presence of posterior cruciate ligament (cruciate retaining vs. posterior stabilized) and bearing articulation (fixed vs. mobile). Unicompartmental knee arthroplasty is used through minimally invasive surgery with relatively good results. Still, liner wear and limitation in the range of motion were concerns, prompting the development of highly cross-linked polyethylene and hyperflexion design prostheses. Although there have been a number of improvements in the design and concepts behind hip joint arthroplasty for many years, fixation methods and bearing surfaces are still in debate. Future developments in total joint arthroplasty should be focused on improved function, wear reduction, enhanced kinematics, and increased range of motion. We can look forward to further advancements in total joint arthro-plasty in the area of new materials and designs.

Four Cases of Multiple Epiphyseal Dysplasia in One Family / 대한정형외과학회잡지

The clinical entity of Dysplasia Epiphyseal Multiplex was first descrihed by Fairbank in 1935, characterized by the disturbance of endochondral ossification in hoth epiphyseal centers and regions of physeal growth. It manifests itself radiologically as late appearance and mottling of the ossification centers and clinically as short stature, stubby digits and painful stiffness of multiple joints. It is typically transmitted as an autosomal dominant trait though recessive forms have been described. The spine is normal apart from a mild increased lumbar lordosis. Many patients are referred to an orthopaedic surgeon for bilateral Perthes disease, as was one of the authors cases. This Paper reports four cases of multiple epiphyseal dysplasia which affected one family.

Autotransfusion in Total Joint Arthroplasty / 대한정형외과학회잡지

We present a review of 131 cases in which blood was retrieved and reinfused using Constavac Blood Conservation blood retrieval and reinfusion device postoperatively. The total number of cases in this study included 84 THA, 19 Rev. THA, 16 unilateral TKA and 12 bilateral TKA. The examinations of hemoglobin, hematocrit, antithrombin III, fibrinogen and D-dimer were initiated prospectively before surgery in each case. These parameters were also examined at postoperative day 1 and at day 7 for the evaluation of safety of Constavace Blood Conservation system. The aerobic and anaerobic bacterial culture tests of draining blood were also taken. The results were as follows: 1. The amount of total blood lost averaged 1264±466cc in THA, 2187±632cc in Rev. THA, 1651±543cc in unilateral TKA and 3445±1532cc in bilateral TKA. 2. The amount of blood retrieved and transfused averaged 499±227cc(39% of total lost blood) in THA, 578±527cc(26%) in Rev. THA. 953±451cc(58%) in unilateral TKA and 2219±1191cc(64%) in bilateral TKA. The amount of reinfusion averaged 71% of blood retrieved in THA, 62% in Rev. THA, 80% in unilateral TKA and 84% in bilateral TKA. 3. Fifty one cases out of 84 cases in THA and 14 case out of 28 cases in TKA underwent operation without homologous blood replacement. In the remaining cases, transfused banked blood averaged 364cc(29% of total lost blood) in THA, 620cc(27%) in Rev. THA, 485cc(29%) in unilateral TKA and 914cc(26%) in bilateral TKA. 4. There were no significant change in hemoglobin and hematocrit at postoperative day 7 compared with the preoperative state. 5. The antithrombin III, fibrinogen and D-dimer were converted to normal range at postoperative day 7. 6. The aerobic and anaerobic bacterial culture tests of reinfusing blood proved to be negative in all cases.