Practical Surgical Techniques for Revision Total Hip Arthroplasty.

Although total hip arthroplasty is an extremely successful procedure, the continual increase in the number of total hip arthroplasties that are performed is associated with the substantial burden of revision total hip arthroplasty. Modes of total hip arthroplasty failure include instability, aseptic loosening, infection, periprosthetic fracture, hardware failure, and component wear, all of which are indications for revision total hip arthroplasty. Surgeons must have a sound preoperative revision total hip arthroplasty plan and must be familiar with a variety of component removal and exposure techniques, such as the extended trochanteric osteotomy. Alternative surgical plan(s) and extra implants for reconstruction on both the acetabular and femoral sides should be available in anticipation of unexpected findings. Component removal and exposure techniques can be refined to avoid complications and achieve a successful outcome in patients who undergo revision total hip arthroplasty.

Complete Eradication of Biofilm From Orthopedic Materials.

BACKGROUND: Interest exists in finding alternatives to current management strategies in periprosthetic joint infections, which typically include a 2-stage revision with placement of an antibiotic spacer and delayed placement of a new implant. We studied the efficacy of autoclaving, ultrasonication, and mechanical scrubbing for sterilization and biofilm eradication on infected cobalt-chrome discs. METHODS: Strains of Staphylococcus aureus MRSA252 or Staphylococcus epidermidis RP62A were grown on the discs. For each strain, discs were divided into 5 groups (5 discs each) and exposed to several sterilization and biofilm eradication treatments: (1) autoclave, (2) autoclave + sonication, (3) autoclave + saline scrub, (4) autoclave + 4% chlorhexidine (CHC) scrub, and (5) autoclave + sonication + CHC scrub. Sterilization and biofilm eradication were quantified with crystal violet assays and scanning electron microscopy. RESULTS: Relative to nontreated controls, autoclaving alone reduced biofilm load by 33.9% and 54.7% for MRSA252 and RP62A strains, respectively. Biofilm removal was maximized with the combined treatment of autoclaving and CHC scrub for MRSA252 (100%) and RP62A (99.5%). The addition of sonication between autoclaving and CHC scrubbing resulted in no statistically significant improvement in biofilm removal. High-resolution scanning electron microscopy revealed no cells or biofilm for this combined treatment. CONCLUSION: Using 2 commonly encountered bacterial strains in periprosthetic joint infection, infected cobalt-chrome discs were sterilized and eradicated of residual biofilm with a combination of autoclaving and CHC scrubbing.

The Factors Influencing the Refracture of Pediatric Forearms.

PURPOSE: Pediatric forearm fractures are common and usually heal uneventfully. The purpose of this study was to review the refracture rate and to identify trends and risk factors that may lead to a refracture. METHODS: Using current procedure terminology code and subsequent chart review we retrospectively identified 2590 patients who sustained forearm fractures over the past 10 years (2000 to 2010) and were treated at a single, large pediatric orthopaedic practice. RESULTS: We identified 37 patients who met our search criterion which yielded a refracture rate of 1.4%. Average length of immobilization was 72.2 days for initial fractures and 98.2 days for refractures. Average time to refracture after declared healing of initial injury was 128.7 days with 36% of refractures occurring within 6 weeks of clinical clearance. Fractures with ≥ 15 degrees angulation refractured earlier (mean 40 d). Seventy-one percent (71%) of patients with refractures had ≥ 10 degrees residual angulation at the time of union of the initial fracture. There was complete radiographic healing in 72% of patients that subsequently refractured. Forearm fractures that refractured most commonly occurred in the middle third (72%), with 24% in the proximal third and 4% in the distal third. Only 2 of 28 patients required surgical instrumentation of the forearm to achieve union of the refracture. We identified a trend toward longer immobilization and time to clinical clearance following a refracture, 76.4 versus 104.2 days. CONCLUSIONS: Over the past 10 years, our clinical data identifies a 1.4% refracture rate, which is significantly less than the previously published rate of 5%. Fractures with greater residual angulation (> 15 degrees) showed a tendency toward earlier refracture and may warrant longer immobilization. Forearm refractures united in most instances with closed treatment. Our treatment with cast or protective brace immobilization and limitation of activity until complete radiographic union likely influences our improved refracture rates.