Patient's perspective on direct anterior versus posterior approach total hip arthroplasty.

PURPOSE: Total hip arthroplasty approach comparison focused on patient's perspective. The direct anterior approach (DAA) has gained immense popularity in the last decade and is widely advocated as a superior approach in terms of quicker recovery and better overall outcome. However, the question if the level of DAA promotion is justified seems to be rarely posed. METHODS: A single-surgeon consecutive series of patients who underwent bilateral THA, one in DAA and the other in posterior approach (PA). The same implant design and same component sizes were used for the both sides. All the operations were performed by a single surgeon under the same pre- and post-operative care protocol. RESULTS: Twenty-one patients underwent bilateral THA, mean age 60.09 years. Oxford Hip Score (OHS) was used for functional outcome assessment. There were no statistically significant differences between two approaches in terms of functional outcome (mean OHS for DAA series was 42.95 and that for the PA was 43.38, p 0.07 at an alpha level of 0.05). Fifteen patients gave the advantage to PA, and six patients favoured DAA. CONCLUSION: By study design, we tried to reduce the biases and acquire approach appraisal from patient's perspective. We anticipated the outcome in favour of DAA, but the results favoring PA came as a surprise. Future prospective randomized studies on evaluation of DAA and other approaches not only from surgeon's or industry's point of view, performed on a larger and more uniform groups, are warranted to further explore the subjective differences between DAA and PA.

Ertapenem Articulating Spacer for the Treatment of Polymicrobial Total Knee Arthroplasty Infection.

Introduction. Periprosthetic joint infections (PJIs) are the primary cause of early failure of the total knee arthroplasty (TKA). Polymicrobial TKA infections are often associated with a higher risk of treatment failure. The aim of the study was to assess the efficacy of ertapenem loaded spacers in the treatment of polymicrobial PJI. Methods. There were 18 patients enrolled; nine patients with polymicrobial PJI treated with ertapenem loaded articulating spacers were compared to the group of 9 patients treated with vancomycin or ceftazidime loaded spacers. Results. Successful reimplantation with revision implants was possible in 66.67%. Ertapenem spacers were used in 6 cases in primary two-stage procedure and in 3 cases in secondary spacer exchange. Successful infection eradication was achieved in all cases; final reimplantation with revision knee arthroplasty implants was possible in 6 cases. Conclusion. Ertapenem can be successfully used as antimicrobial addition to the cement spacers in two-stage revision treatment of polymicrobial PJIs. However, this type of spacer may also be useful in the treatment of infections caused by monomicrobial extended spectrum beta-lactamases producing gram-negative bacilli. Further clinical studies are required to evaluate the efficacy and safety of ertapenem spacers in the treatment of polymicrobial and monomicrobial PJIs.

Antibiotic-loaded cement spacer for treatment of Klebsiella infected total hip and knee arthroplasty.

BACKGROUND/AIM: Infection following total hip arthroplasty (THA) or total knee arthoplasty (TKA) may have devastating consequences. Some bacterial strains are often encountered as agents of these infections, others occur less frequently but are sometimes burdened with more severe complications. Kebsiella spp. are uncommon causes of THA or TKA infection. The aim of this study was to identify an effective treatment algorithm for multidrug resistant Kebsiella spp. caused THA or TKA infections. METHODS: During the 3-year period, from January 1 2009 to December 31 2011, we registered and treated 5 patients with THA or TKA multidrug resistant Klebsiella spp. caused infection. All the patients were primarily operated in other institutions, and were admitted in our clinic after the onset of infection symptoms. In three of the cases Klebsiella infection was complicated by additional infection (Staphyloccocus aureus, Pseudomonas aeruginosa and Serratia marscescens). In 3 of the cases we performed revision arthroplasty after double exchange of antibiotic-loaded articulating cement spacer, and in 2 of the cases the standard two-stage revision approach with one antibiotic cement spacer exchange was applied. RESULTS: The mean length of follow-up after reimplantation surgery was 17.1 months (range 2-31 months). One patient died 2 months after the final reimplantation procedure. The initial Klebsiella infection was eradicated in all the patients. At the end follow-up after definitive reimplantation, the patients had no clinical, laboratory or microbiological parameters positive for active infection. CONCLUSION: According to our experience with multidrug-resistant Klebsiella TKA/THA infections, two-stage approach, in some cases with double articulating cement spacer exchange prior to definitive reimplantation, is the most effective treatment option.

Does timing of surgery affect the outcome of open articular distal humerus fractures.

BACKGROUND: Open intraarticular distal humerus fractures classified as Orthopaedic Trauma Association (OTA) 13 C may have devastating consequences for patient's quality of life, especially if leading arm in younger active patient is involved. We conducted a study to determine whether the timing of open reduction and internal fixation of open intraarticular distal humerus fractures affects the outcomes. PATIENTS AND METHODS: Multicentric prospective study: In the first group, there were 15 patients, 10 men and 5 women, mean age 38.7 years, operated in <6 h of injury. In the second group 17 patients, 11 men and 6 women, mean age 42.3 years operatively treated in delayed settings, mean delay to operation 4.6 days of injury. In both groups, patients had open distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. Functional outcome was assessed with Mayo elbow performance score and Disabilities of Arm and Shoulder and Hand (DASH). Mean Mayo elbow performance (MEP) score in the first group was 71 (range 30-100); in the second, mean MEP was 64.3 (range 25-100). The mean DASH in the first group was 27.89 (range from 1.7 to 75.8), and in the second, mean DASH score was 32.6 (range 5.8-77.5). There were no statistically significant differences between two groups, MEP t(28)=0.935, p<0.358; DASH t(28)=-0.636, p<0.530. CONCLUSION: Our study shows that early open reduction and internal fixation of open distal articular humerus fractures reduces the hospital stay, but does not significantly affect the overall outcomes and complications.

Infected total knee arthroplasty treatment outcome analysis.

BACKGROUND/AIM: Infected total knee arthroplasty (TKA) is a topic of great importance, because its diagnosing and treatment requires a lot of resources, and often has an unsatisfactory outcome. The aim of this study was to analyze the outcome of the treatment of infection developed following TKA. METHODS: This retrospective study of infected TKAs was performed in the period from 1998 to 2008 in the Orthopedics & Traumatology Clinic of the Military Medical Academy (MMA) in Belgrade. A total of 654 primary and revised TKAs were performed in the said period. We registered and surgically treated 28 infected TKAs (primary TKAs: MMA--22, other institutions--6). The incidence of TKA infection in the MMA was 3.36%. The most common pathogens were: Staphylococcus aureus--14 (50%) cases, and Staph. epidermidis--3 (10.7%) cases. Other isolated pathogens were: Enterococcus faecalis, Klebsiella pneum., Klebsiella spp., Streptoccocus viridans, Seratia spp, Micrococcus luteus and Peptostreptococcus spp. In one case we had mixed anaerobic flora, and in 3 cases cultures were negative. We analyzed diagnostic challenges, risk factors (such as age and previous viscosupplementation) and treatment outcomes in our series of infected TKAs. RESULTS: In our series 2 infections healed after iv antibiotics and debridement, 1 patient responded to open debridement with component retention, 4 patients responded fully to one-stage reimplantation, 10 cases responded fully to two-stage reimplantation, 11 patients ended with arthrodesis and we had 1 patient withabove knee amputation. CONCLUSION: Two-stage reimplantation remains gold standard for treatment of infected TKA, and we recommend it as treatment of choice for eradication of infection. The antibiotic loaded spacer prothesis concept in most cases allows infection eradication, good function and high patient satisfaction.

Arthroscopic partial medial meniscectomy.

BACKGROUND/AIM: Meniscal injuries are common in professional or recreational sports as well as in daily activities, If meniscal lesions lead to physical impairment they usually require surgical treatment. Arthroscopic treatment of meniscal injuries is one of the most often performed orthopedic operative procedures. METHODS: The study analyzed the results of arthroscopic partial medial meniscectomy in 213 patients in a 24-month period, from 2006, to 2008. RESULTS: In our series of arthroscopically treated medial meniscus tears we noted 78 (36.62%) vertical complete bucket handle lesions, 19 (8.92%) vertical incomplete lesions, 18 (8.45%) longitudinal tears, 35 (16.43%) oblique tears, 18 (8.45%) complex degenerative lesions, 17 (7.98%) radial lesions and 28 (13.14%) horisontal lesions. Mean preoperative International Knee Documentation Committee (IKDC) score was 49.81%, 1 month after the arthroscopic partial medial meniscectomy the mean IKDC score was 84.08%, and 6 months after mean IKDC score was 90.36%. Six months after the procedure 197 (92.49%) of patients had good or excellent subjective postoperative clinical outcomes, while 14 (6.57%) patients subjectively did not notice a significant improvement after the intervention, and 2 (0.93%) patients had no subjective improvement after the partial medial meniscectomy at all. CONCLUSION: Arthroscopic partial medial meniscetomy is minimally invasive diagnostic and therapeutic procedure and in well selected cases is a method of choice for treatment of medial meniscus injuries when repair techniques are not a viable option. It has small rate of complications, low morbidity and fast rehabilitation.

[Revision hip arthroplasty by Waldemar Link custom-made total hip prosthesis].

BACKGROUND: The number of patients undergoing hip arthroplasty revision is constantly growing. Especially, complex problem is extensive loss of bone stock and pelvic discontinuity that requires reconstruction. CASE REPORT: The paper presented a 50-year old patient, who ten years ago underwent a total cement artrhroplasty of the left hip. A year after the primary operation the patient had difficulties in walking without crutches. Problems intensified in the last five years, the patient had severe pain, totally limited movement in the left hip and could not walk at all. Radiographically, we found loose femoral component, massive loss of bone stock of proximal femur, acetabular protrusion and a consequent pelvic discontinuity. Clinically, a completely disfunctional left hip joint was registered (Harris hip score--7.1). We performed total rearthroplasty by a custom-made Waldemar Link total hip prosthesis with acetabular antiprotrusio cage and compensation of bone defects with a graft from the bone bank. A year after the operation, we found clinically an extreme improvement in Harris hip score--87.8. Radiographically, we found stability of implanted components, a complete graft integration and bone bridging across the site of pelvic discontinuity. CONCLUSION: Pelvic discontinuity and massive loss of proximal femoral bone stock is a challenging and complex entity. Conventional prostheses cannot provide an adequate fixation and stability of the hip. Application of custom-made prosthesis (measured specificaly for a patient) and additional alografting bone defects is a good method in revision surgery after unsuccessful hip arthroplasty with extensive bone defects.