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Introduction: The risk of prosthetic joint infection (PJI) in mega-prosthesis for malignancy is increased compared with non-tumor cases. While several studies describe PJI in tumor-related arthroplasty, prospective studies comparing infection characteristics among different joints are limited. The present study analyzes mega-arthroplasty for hip, knee, and shoulder malignancy and compares the epidemiology, diagnosis, microbe spectrum, treatments, and outcomes between the different entities. Methods: The retrospective inclusion criteria were as follows: (1) mega-arthroplasty (2) in the hip, knee, or shoulder joint and a total femur arthroplasty (3) following a malignant bone tumor or metastasis (4) between 1996 and 2019. All included patients were prospectively followed and invited for a renewed hospital examination, and their PJI characteristics (if identified) were analyzed using both retrospective as well as newly gained prospective data. A PJI was defined according to the Infectious Disease Society of America (IDSA) and re-infection was defined according to the modified Delphi Consensus criteria. Results: In total, 83 cases of tumor mega-arthroplasty at a mean follow-up of 3.9 years could be included (32 knee, 30 hip, and 19 shoulder cases and 2 cases of total femur arthroplasty). In total, 14 PJIs were identified, with chondrosarcoma in 6 and osteosarcoma in 3 being the leading tumor entities. Knee arthroplasty demonstrated a significantly higher rate of PJI (p = 0.027) compared with hips (28.1% vs. 6.7%), while no significant difference could be found between the knee and shoulder (10.5%) (p = 0.134) or among shoulder and hip cases (p = 0.631). The average time of PJI following primary implantation was 141.4 months in knee patients, 64.6 in hip patients, and 8.2 months in shoulder patients. Age at the time of the primary PJI, as well as the time of the first PJI, did not show significant differences among the groups. Thirteen of the fourteen patients with PJI had a primary bone tumor. Statistical analysis showed a significant difference in the disadvantage of primary bone tumors (p = 0.11). While the overall cancer-related mortality in the knee PJI group (10%) was low, it was 50% in the hip and 100% in the shoulder group. Conclusion: The risk of PJI in knee tumor arthroplasty is significantly increased compared with hips, while cancer-related mortality is significantly higher in hip PJI cases. At the same time, mega-prostheses appear to be associated with a higher risk of infection due to a primary bone tumor compared with metastases. The study confirms existing knowledge concerning PJI in tumor arthroplasty, while, being one of the few studies to compare three different joints concerning PJI characteristics.

BACKGROUND Four-corner fusion (4CF) is a motion sparing salvage procedure that is used to treat osteoarthritis secondary to advanced scapholunate collapse or longstanding scaphoid nonunion advanced collapse. Little is known about the long-term survivorship and outcomes of 4CF. AIM To report on clinical and functional long-term outcomes as well as conversion rates to total wrist fusion or arthroplasty. METHODS The systematic review protocol was registered in the international prospective register of systematic reviews (PROSPERO) and followed the PRISMA guidelines. Original articles were screened using four different databases. Studies with a minimum Level IV of evidence that reported on long-term outcome after 4CF with a minimum follow-up of 5 years were included. Quality assessment was performed using the Methodological Index for Non-Randomized Studies criteria. RESULTS A total of 11 studies including 436 wrists with a mean follow-up of 11 ± 4 years (range: 6-18 years) was included. Quality assessment according to Methodological Index for Non-Randomized Studies criteria tool averaged 69% ± 11% (range: 50%-87%). Fusion rate could be extracted from 9/11 studies and averaged 91%. Patient-reported outcomes were extracted at last follow-up from 8 studies with an average visual analog scale of 1 ± 1 (range: 0-2) and across 9 studies with an average Disabilities of the Arm, Shoulder and Hand score of 21 ± 8 (range: 8-37). At last follow-up, the cumulative conversion rate to total wrist fusion averaged 6%. There were no conversions to total wrist arthroplasty. CONCLUSION The 4CF of the wrist is a reliable surgical technique, capable of achieving a good long-term patient satisfaction and survivorship with low rates of conversion to total wrist fusion.

Osteoarthritis (OA) is the most common degenerative joint disorder worldwide and to date no regenerative treatment has been established in clinical practice. This review evaluates the current literature on the clinical translation of mesenchymal stromal cell (MSC)-based therapy in OA management with a focus on safety, outcomes and procedural specifics. PubMed, Cochrane Library and clinicaltrials.gov were searched for clinical studies using MSCs for OA treatment. 290 articles were initially identified and 42 articles of interest, including a total of 1325 patients, remained for further examination. Most of the included studies used adipose tissue-derived MSCs or bone-marrow-derived MSCs to treat patients suffering from knee OA. MSC-based therapy for knee OA appears to be safe and presumably effective in selected parameters. Yet, a direct comparison between studies was difficult due to a pronounced variance regarding methodology, assessed outcomes and evidence levels. Intensive scientific engagement is needed to identify the most effective source and dosage of MSCs for OA treatment in the future. Consent on outcome measures has to be reached and eventually patient sub-populations need to be identified that will profit most from MSC-based treatment for OA.

Introduction: Since 06/2013, periprosthetic joint infections (PJI) were treated with a standardized therapeutic and diagnostic algorithm in a separated septic-surgery department by an interdisciplinary team of surgeons, orthopedics, microbiologist, and pathologists. The hypothesis is put up, that such an interdisciplinary and standardized approach is able to improve the outcome compared to a conventional procedure. Methods: Publications 1 and 2 are retrospective studies, the third a prospective consecutive study. Results: Publication 1: 95 PJI cases, treated with a two-stage exchange in the interdisciplinary and standardized system in the years 2013 – 2016, were included (49 hips, 46 knees). The comparison group was a non-standardized, non-interdisciplinary and conventionally treated group from the same clinic of the years 2009 – 2011 (46 hips, 40 knees). Despite a significantly higher CCI (Charlson Comorbidity Index, 3.9, 3.1, P=0.009), rate of septic indicated pre-revisions (52.6%, 36%, p=0.025), and trend towards a higher average age (69.0 years, 66.2 years, p=0.075) and more polymicrobial cases (47.3%, 33.7%, p=0.062), both the relapse rate (suspected infection persistence), and time interval between ex- and reimplantation (66.6 days, 80.7 days, p 1mg/dl, X-ray, Leucocytes in aspiration >1700/µl). In 91.6%, a microbe was then found intraoperatively in the hip. In the knee, this was only the case in 68.7%. However, here other definitive infection signs were found in 93.7% (e.g. Krenn Morawietz type II/III). Publication 3: In the years 2015/16, 8 PJI with co-existing fractures were identified (one Vancouver Typ B1, three type B2/3, four type C). Following a specialized and standardized three-step procedure (explanation, fracture stabilization, two-stage reimplantation) the combined relapse and new infection rate was 12.5%, the total revision rate 37.5% and the fracture healing rate 62.5% (follow-up 34±8 months). Conclusion: An interdisciplinary and standardized treatment system is one possible solution for the increasing problem of PJI. The indication for a revision can solely be based on paraclinical criteria without a preoperative microbe detection. A standardized three step-based procedure in PJI with co-existing fractures achieved infection consolidation and limb preservation in all cases., Seit dem 06/2013 werden periprothetische Infektionen (PPI) an der Charité mit ei-nem neuen standardisierten Diagnostik- und Therapiealgorithmus in einer getrennten und spezia-lisierten septisch chirurgischen Abteilung von einem interdisziplinären Team aus Chirurgen, Or-thopäden, Mikrobiologen und Pathologen behandelt. Es wurde die These aufgestellt, dass ein derartiger interdisziplinärer und standardisierter Therapieansatz das Behandlungsergebnis im Vergleich zu einem konventionellen Vorgehen verbessern kann. Methodik: Die Patientendaten der ersten und zweiten Publikation wurden retrospektiv erhoben, die der dritten Publikation prospektiv und konsekutiv. Ergebnisse: Publikation 1: Es konnten 95 PPI Fälle, die mit einem zweizeitigen Wechsel durch einen interdisziplinären, zentralisierten und standardisierten Therapiealgorithmus in den Jahren 2013 – 2016 behandelt wurden, eingeschlossen werden (49 Hüften, 46 Knie). Als Vergleichs-gruppe diente eine konventionell behandelte, nicht standardisierte und nicht interdisziplinär the-rapierte Gruppe aus derselben Klinik der Jahre 2009 bis 2011 (46 Hüften, 40 Knie). Trotz eines signifikant höheren CCI (Charlson Comorbidity Index, 3,9, 3,1, P=0,009), einer höheren Rate septisch indizierter Vorrevisionen (52,6%, 36%, p=0,025), sowie eines Trends hin zu einem hö-heren Alter (69,0 Jahre, 66,2 Jahre, p=0,075) und mehr polymikrobiellen Erregerfällen (47,3%, 33,7%, p=0,062), konnte die Reinfektionsrate (vermutete Infektionspersistenz) von 10,4% auf 3,1% (p=0,048), sowie das Zeitintervall zwischen Aus- und Wiedereinbau (66,6 Tage, 80,7 Tage, p1 mg/dl, Röntgen, Leukozyten Punktat >1700/μl). In 91,6% konnte in den Patienten mit PPI der Hüfte intraoperativ ein Erreger identifiziert werden. Im Knie war dies nur in 68,7% der Fall. Jedoch konnten hier in 93,7% andere eindeutige Infekt Zeichen identifiziert werden (z.B. Krenn Morawietz Typ II/III). Publikation 3: In den Jahren 2015/16 konnten 8 PPI eingeschlossen werden bei denen parallel eine zusätzliche periprothetische Fraktur bestand (ein-mal Vancouver Typ B1, dreimal Typ B2/3, viermal Typ C). Mit einem standardisierten drei-schrittigen Therapieansatz (Explantation, Frakturstabilisation, zweizeitige Reimplantation) be-trug die kombinierte Neu- und Reinfektionsrate 12,5%, die Gesamtrevisionsrate 37,5% und die Fraktur-Heilungsrate 62,5% (follow-up 34±8 Monate). Schlussfolgerung: Ein interdisziplinärer und standardisierter Behandlungsansatz ist ein mögli-cher Lösungsansatz für das zunehmende Problem der PPI. Die Indikation zur Revision kann nur anhand bestimmter paraklinischer Kriterien ohne präoperativen Erregernachweis gestellt werden. Ein standardisiertes drei-schrittiges Vorgehen bei PPI mit Frakturen konnte in allen Fällen Infekt Konsolidaton und Gelenkerhalt ermöglichen.

Fragestellung: Periprothetische Infektionen (PPI) sind eine diagnostische und therapeutische Herausforderung. Ein erneutes Auftreten einer Infektion oder eine Persistenz nach septischer Revision stellt eine äußerst frustrane Situation für den Patient und das behandelnde Team dar. Die[zum vollständigen Text gelangen Sie über die oben angegebene URL], Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2019)

Fragestellung: Periprothetische Infektionen (PPI) sind eine schwerwiegende Komplikation in der Endoprothetik, deren erfolgreiche Therapie eine enorme Herausforderung darstellt. Der Erfolg hängt unter anderem von der Erfahrung des behandelnden Teams und vom zugrundeliegenden Therapiekonzept ab. [zum vollständigen Text gelangen Sie über die oben angegebene URL], Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2018)

Fragestellung: Die Behandlung einer Periprothetischen Infektion (PPI) erfordert ein striktes und aufwendiges therapeutisches Vorgehen, welches für den Erfolg der Therapie essentiell ist und sich grundlegend von dem, einer aseptischen Problematik unterscheidet. Hierfür ist die präoperative[zum vollständigen Text gelangen Sie über die oben angegebene URL], Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2018)

Aim of this study. Periprosthetic joint infections (PJIs) require a special antimicrobial regimen, fundamentally different from an aseptic treatment, making a correct preoperative diagnosis essential. However, a successful preoperative microbe detection is not always possible. We wanted to find out (1) if a preoperative microbe detection is a prerequisite before starting a septic revision in suspected PJIs or if the preoperative diagnosis can solely be based on (para) clinical signs (persistent CRP >1 mg/dl, early X-ray loosening signs in the first 5 years, leucocytes joint aspiration >1700/mu l, conspicuous history, and clinical signs like redness, pain, hyperthermia, swelling, and loss of function); (2) if patients with and without preoperative microbe detection have a different outcome; and (3) if the microbial growth is the most important criterion of a multifactorial PJI definition. Methods. We included all first-line two-stage hip (49) and knee (47) revisions, performed in our department from 06/2013 on, with an available 2-year follow-up. A PJI was defined as one of the following four criteria: fistula or purulence, Krenn Morawietz type 2 or 3, joint aspirate >2000/mu l leukocytes or >70% granulocytes, and microbial growth. This multifactorial PJI definition was based on the European Bone and Joint Infection Society (EBJIS). The standardized diagnostic algorithm is described in detail. Results. (1) 24 hip and 16 knee cases were treated without preoperative microbe detection solely on the basis of a (para) clinical diagnosis (see above). In the hip 91.6% (22 of 24 cases) showed an intraoperative microbe detection. In the knee, in 68.7% (11 of 16 cases) a microbe was detected intraoperatively and in 93.7% (15 of 16) at least one secure PJI criterion could be confirmed intraoperatively. (2) No statistical significant (p.517) difference between patients with (n = 56, reinfection rate 8.9%) and without (n = 40, 15%) preoperative microbe detection was found in a 2-year follow-up. (3) Microbial growth remains the overall (pre- and intraoperatively) most important criterion (hip 95.9%; knee 89.3%), followed by Krenn Morawietz for the intraoperative diagnosis (hip 67.3%, knee 48.9%), and joint aspiration for the knee and fistula for the hip, respectively, as preoperative criteria. Conclusion. High rates of intraoperatively fulfilled EBJIS PJI criteria show that a preoperative microbe detection is not necessary before intervening in suspected PJIs. The indication for a septic revision can solely be based on (para) clinical signs. The new established diagnostic algorithm based on a multifactorial PJI definition showed high precision in finding PJIs.