Articular spacers in two-stage revision arthroplasty for prosthetic joint infection of the hip and the knee.

Use of articular antibiotic-eluting cement spacers during two-stage revision arthroplasty for prosthetic joint infection (PJI) is a long-established and proven adjunctive technique during first-stage surgery. Articular spacers come in many forms, either static or dynamic. The authors present an instructional review of current evidence regarding their use. A total of 45 studies (for spacer use in PJI involving either hip or knee) were analysed for data regarding eradication rate, functional outcomes, mechanical complications and the impact on second-stage surgery. A large number of case series and retrospective cohort studies were retrieved, with only a small number of prospective studies (2). High levels of infection eradication were commonly reported (>80%). Outcome scores were commonly reported as indicating good-to-excellent function and pain levels. Second-stage procedures were often not required when dynamic spacers were used. Static spacers were associated with more mechanical complications in both the hip and the knee. In the hip, dynamic spacers were more commonly associated with instability compared to static spacers. Consideration should be given to the use of dual-mobility or constrained definitive acetabular components in these cases at second-stage surgery. The use of antibiotic-eluting polymethylmethacrylate articular spacers in two-stage revision for PJI of hip and knee arthroplasty achieves a high rate of infection eradication. Dynamic spacers may confer a variety of benefits compared to static spacers, with a similar rate of infection eradication.

Reverse hybrid total hip arthroplasty.

Aims: This study aimed to evaluate implant survival of reverse hybrid total hip arthroplasty (THA) at medium-term follow-up. Patients and Methods: A consecutive series of 1082 THAs in 982 patients with mean follow-up of 7.9 years (5 to 11.3) is presented. Mean age was 69.2 years (21 to 94). Of these, 194 (17.9%) were in patients under 60 years, 663 (61.3%) in female patients and 348 (32.2%) performed by a trainee. Head size was 28 mm in 953 hips (88.1%) or 32 mm in 129 hips (11.9%). Survival analysis was performed and subgroups compared using log rank tests. Results: Ten-year survival (122 hips at risk) was 97.2% (95% confidence interval (CI) 95.77 to 98.11) for all-cause revision. There was no difference in survival by age (p = 0.50), gender (p = 0.78), head size (p = 0.63) or surgeon grade (p = 0.36). No acetabular components underwent revision for aseptic loosening in the entire series. Four (0.4%) aseptic stem failures occurred early at a mean of 2.5 years (0.6 to 4.8) and were associated with age under 60 years (p = 0.015). There was no difference in survival by gender (p = 0.12), head size (p = 0.43) or surgeon grade (p = 0.77) for stem revision. Conclusion: This is the largest reported study into reverse hybrid THA and it confirms successful outcomes, irrespective of age, gender, head size and surgeon grade. Cite this article: Bone Joint J 2018;100-B:1010-17.

Gastroduodenal ulcers in the Helicobacter pylori era.

The aim of the study was to evaluate the current spectrum of gastroduodenal ulcers in children referred to a regional paediatric unit in the United Kingdom. During a 5-y period (1994-98), all children with a visibly discrete gastric and/or duodenal ulcer diagnosed at endoscopy were prospectively identified. Patients with ulcers associated with Helicobacter pylori gastritis underwent repeat endoscopy 2-3 mo after medical treatment. Thirty-seven children, 21 boys and 16 girls of median age 11 y (range 7 mo to 16 y), had gastric and/or duodenal ulceration. Specific aetiological factors were identified in 21 of 22 with H. pylori negative ulcers, including Crohn's disease (n = 6), coeliac disease (n = 4) and treatment with ulcerogenic drugs (n = 4). Fifteen children (41%) had ulcers associated with H. pylori gastritis, including all 10 children with a chronic ulcer. Endoscopically confirmed ulcer healing was achieved in 14 of these using a 1 wk triple therapy regimen (omeprazole and a combination of two antibiotics). In conclusion, the recognized spectrum and the management of gastroduodenal ulceration have changed during the last decade. Although H. pylori gastritis is an important aetiological factor, a wide range of other conditions needs to be considered. Surgical intervention is only rarely necessary.

Out-patient follow-up after total hip replacement in one health region.

A postal survey was carried out of all orthopaedic surgeons in the West Yorkshire Health region enquiring about out-patient follow-up practices after total hip replacement. Follow-up is advised to detect problems that can more effectively be resolved if detected early. A huge variation in the number, timing and nature of appointments following discharge was demonstrated. The total length of follow-up varied between 3 months and indefinite follow-up. The number of visits in the first post-operative year varied between one and four. The considerable variation in post surgery follow-up of these patients has important cost implications. Some patients will have unnecessary appointments whereas others will be inadequately reviewed. Guidance is required on the appropriate review of these patients which will allow early detection of joint failure in a way that is efficient in terms of the time and cost of out-patient follow-up.

Superior mesenteric artery syndrome presenting with acute massive gastric dilatation.

A 14-year-old girl presenting with acute massive gastric dilatation secondary to duodenal obstruction by the superior mesenteric artery is described. The diagnosis was facilitated by contrast-enhanced abdominal computerized tomography. She was successfully treated by gastrostomy and subsequent duodenal derotation. This unique presentation of the superior mesenteric artery syndrome is discussed.