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Introduction: Debridement, antibiotics and implant retention (DAIR) procedures are effective treatments for acute postoperative or acute hematogenous periprosthetic joint infections. However, literature reporting on the effectiveness of DAIR procedures performed after a one- or two-stage revision because of a prosthetic joint infection (PJI) (PJI-related revision arthroplasty) is scarce. The aim of this study is to retrospectively evaluate the infection control after 1 year of a DAIR procedure in the case of an early postoperative infection either after primary arthroplasty or after PJI-related revision arthroplasty. Materials and methods: All patients treated with a DAIR procedure within 3 months after onset of PJI between 2009 and 2017 were retrospectively included. Data were collected on patient and infection characteristics. All infections were confirmed by applying the Musculoskeletal Infection Society (MSIS) 2014 criteria. The primary outcome was successful control of infection at 1 year after a DAIR procedure, which was defined as the absence of clinical signs, such as pain, swelling, and erythema; radiological signs, such as protheses loosening; or laboratory signs, such as C-reactive protein (CRP) () with no use of antibiotic therapy. Results: Sixty-seven patients were treated with a DAIR procedure (41 hips and 26 knees). Successful infection control rates of a DAIR procedure after primary arthroplasty (n=51) and after prior PJI-related revision arthroplasty (n=16) were 69 % and 56 %, respectively (p=0.38). The successful infection control rates of a DAIR procedure after an early acute infection (n=35) and after a hematogenous infection (n=16) following primary arthroplasty were both 69 % (p=1.00). Conclusion: In this limited study population, no statistically significant difference is found in infection control after 1 year between DAIR procedures after primary arthroplasty and PJI-related revision arthroplasty.

BACKGROUND Two-stage revision arthroplasty with an antibiotic-loaded spacer is the treatment of choice in chronically infected total hip arthroplasties. Interval spacers can be functional articulating or prefabricated. Functional results of these spacers have scarcely been reported. AIM To compare retrospectively the patient reported outcome and infection eradication rate after two-stage revision arthroplasty of the hip with the use of a functional articulating or prefabricated spacer. METHODS All patients with two-stage revision of a hip prosthesis at our hospital between 2003 and 2016 were included in this retrospective cohort study. Patients were divided into two groups; patients treated with a functional articulating spacer or with a prefabricated spacer. Patients completed the Hip Osteoarthritis Outcome Score and the EQ-5D-3L (EQ-5D) and the EQ-5D quality of life thermometer (EQ-VAS) scores. Primary outcomes were patient reported outcome and infection eradication after two-stage revision. The results of both groups were compared to the patient acceptable symptom state for primary arthroplasty of the hip. Secondary outcomes were complications during spacer treatment and at final follow-up. Descriptive statistics, mean and range are used to represent the demographics of the patients. For numerical variables, students’ t-tests were used to assess the level of significance for differences between the groups, with 95% confidence intervals; for binary outcome, we used Fisher’s exact test. RESULTS We consecutively treated 55 patients with a prefabricated spacer and 15 patients with a functional articulating spacer of the hip. The infection eradication rates for functional articulating and prefabricated spacers were 93% and 78%, respectively (P > 0.05). With respect to the functional outcome, the Hip Osteoarthritis Outcome Score (HOOS) and its subscores (all P < 0.01), the EQ-5D (P < 0.01) and the EQ-VAS scores (P < 0.05) were all significantly better for patients successfully treated with a functional articulating spacer. More patients in the functional articulating spacer group reached the patient acceptable symptom state for the HOOS pain, HOOS quality of life and EQ-VAS. The number of patients with a spacer dislocation was not significantly different for the functional articulating or prefabricated spacer group (P > 0.05). However, the number of dislocations per patient experiencing a dislocation was significantly higher for patients with a prefabricated spacer (P < 0.01). CONCLUSION Functional articulating spacers lead to improved patient reported functional outcome and less perioperative complications after two-stage revision arthroplasty of an infected total hip prosthesis, while maintaining a similar infection eradication rate compared to prefabricated spacers.

Background Many PROMs used for evaluation of ankle osteoarthritis are not validated for this purpose. We hypothesize that frequently used PROMs have an early ceiling or floor effect. Methods We prospectively collected data from patients with ankle osteoarthritis between 2011 and 2013. At baseline visit patients completed the Foot and Ankle Outcome Score, the Ankle Osteoarthritis Score, the American Orthopaedic Foot and Ankle Society scale, a visual analogue scale for pain and quality of life. Outcomes were analyzed for floor or ceiling effects. Results 197 patients were included in the study. A floor effect was present for the AOFAS and VAS for pain in all groups. Floor and ceiling effect are absent for the FAOS outcome measure for all groups. Conclusions Physicians should be aware of floor or ceiling effects when evaluating treatment using patient reported outcome measures. The FAOS outcome measure lacks early ceiling or floor effects.

Background: Diagnosis of periprosthetic joint infection (PJI) can be troublesome. Sonication can be a helpful tool in culturing bacteria that are difficult to detect with standard tissue cultures. Aim of this study is to evaluate the clinical importance of our standardized sonication protocol in detecting periprosthetic joint infection.Materials and methods: All patients with revision surgery of a hip or knee prosthesis between 2011 and 2016 were retrospectively reviewed and divided in two groups: clinically suspected of infection or not suspected of infection. For both tissue culture and implant sonication, calculations of sensitivity and specificity were performed. Clinical relevance of sonication was evaluated by calculating in which percentage of patients' sonication influenced clinical treatment.Results: 226 patients with revision of a total hip prosthesis (122 patients) or a total knee prosthesis (104 patients) were included. Sensitivity of perioperatively taken tissue cultures was 94.3% and specificity was 99.3%. For sonication sensitivity was 80.5% and specificity was 97.8%.In the infection group eight patients (9%) with only one positive tissue culture and a positive sonication fluid culture with the same pathogen were found.Interpretation: Although sensitivity and specificity of sonication was lower compared to tissue cultures, periprosthetic joint infection could only be established in 8 patients (9%) suspected of infection because of a positive result of the sonication fluid culture.Sonication leads to clinically relevant changes in treatment and seems therefore to be a helpful diagnostic tool in clinical practice.

Background and purpose — The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI.Patients and methods — A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received.Results — For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28–35), 39 (25–59), and 23 (15–34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24–31), 40 (24–62), and 24 (16–36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders.Interpretation — In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.

BACKGROUND Periprosthetic joint infections (PJIs) are frequently caused by coagulase-negative Staphylococci (CoNS), which is known to be a hard-to-treat microorganism. Antibiotic resistance among causative pathogens of PJI is increasing. Two-stage revision is the favoured treatment for chronic CoNS infection of a hip or knee prosthesis. We hypothesised that the infection eradication rate of our treatment protocol for two-stage revision surgery for CoNS PJI of the hip and knee would be comparable to eradication rates described in the literature. AIM To evaluate the infection eradication rate of two-stage revision arthroplasty for PJI caused by CoNS. METHODS All patients treated with two-stage revision of a hip or knee prosthesis were retrospectively included. Patients with CoNS infection were included in the study, including polymicrobial cases. Primary outcome was infection eradication at final follow-up. RESULTS Forty-four patients were included in the study. Twenty-nine patients were treated for PJI of the hip and fifteen for PJI of the knee. At final follow-up after a mean of 37 mo, recurrent or persistent infection was present in eleven patients. CONCLUSION PJI with CoNS can be a difficult to treat infection due to increasing antibiotic resistance. Infection eradication rate of 70%-80% may be achieved.

Introduction The objective of the present study was to review the current data on the long-term outcomes of posterior malleolar fractures, with special emphasis on the role of the type of treatment, surgical approach, and reduction and internal fixation. Methods The search was limited to skeletally mature patients. Major databases were searched from 1978 to 2014 to identify studies relating to functional outcome, subjective outcome, and radiographic evaluation at least 2 years after either surgical or conservative treatment of posterior malleolar fractures. Results Of 68 initially relevant studies, 19 met our inclusion criteria. A total of 886 fractures were identified in 885 patients. The mean sample size-weighted follow-up period was 3.7 years. Comparable results are achieved when comparing open reduction and internal fixation to conservative treatment for posterior malleolar fractures. Discussion Current consensus suggests posterior malleolar fragments comprising of >25% of the distal tibial plafond as seen on a true lateral radiograph and fragments with more than 2mm dislocation require open reduction and internal fixation of the fragment. The current consensus on treatment of posterior malleolar fractures is neither supported nor disapproved by the available evidence.

No abstract available Keywords: allograft; bone defects; cement extraction; cement retrieval; femoral bone stock; nonantibiotic impregnated allograft; reimplantation; reimplantation timing; resection arthroplasty; stable cement mantle; two-stage exchange arthroplasty.

A case of giant synovial chondromatosis of the hip with extra-articular localisation in the ileopectineal bursa is presented and the literature concerning this condition is reviewed. Synovial chondromatosis is a rare condition of unknown aetiology. A literature search was performed to identify studies describing outcome after surgical treatment of synovial chondromatosis of the hip. Thirteen studies including two hundred-ninety patients could be included. Mean follow-up was fifty-six months. Seven out of two hundred-ninety developed a complication after surgical resection of the lesion. Recurrence rate of synovial chondromatosis is about 19%. Malignant transformation of synovial chondromatosis to chondrosarcoma is extremely rare. No wound infections were reported and avascular necrosis of the femoral head occurred in one patient who was treated with dislocation of the hip during surgery. After resection of synovial chondromatosis excellent functional outcome can be expected.

Purpose The objectives of this comprehensive quantitative review of the treatment of calcific tendinopathy of the rotator cuff were to investigate if there is a sustainable positive effect on outcomes after treatment with high-energy extracorporeal shockwave therapy (ESWT) or ultrasound (US)–guided needling and to compare these results with those of treatment with arthroscopic surgery. Methods The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to conduct this review. A systematic literature search was conducted in December 2014 to identify relevant clinical articles in peer-reviewed journals with at least 6 months' follow-up. Each article was scored using the Coleman Methodology Score. The primary endpoints were functional outcome and radiologic change in the size of the calcific deposit. Results Twenty-two studies were included (1,258 shoulders). The mean Coleman Methodology Score for the included studies was 77.1 ± 9.1. Overall, good to excellent clinical outcomes were achieved after treatment with either high-energy ESWT, US-guided needling, or arthroscopic surgery, with an improvement in the Constant-Murley score ranging between 26.3 and 41.5 points after 1 year. No severe side effects or long-term complications were encountered. Conclusions Patients can achieve good to excellent clinical outcomes after high-energy ESWT, US-guided needling, and arthroscopy for calcific tendinopathy of the shoulder. Side effects and post-treatment complications should be taken into account when a decision is being made for each individual patient. Physicians should consider high-energy ESWT and US-guided needling as minimally invasive treatment options when primary conservative treatment fails. Arthroscopy can safely be used as a very effective but more invasive secondary option, although the extent of deposit removal and the additional benefit of subacromial decompression remain unclear. Level of Evidence Level IV, systematic review of Level I, II, and IV studies.

Background: To prevent postoperative infection the use of systemic antibiotic prophylaxis is common ground. Type of antibiotic used and duration of prophylaxis are subject to debate. In case of suspected early periprosthetic infection a debridement, antibiotics and implant retention (DAIR) procedure is treatment of first choice. This study evaluated the antibiotic prophylaxis and DAIR treatment protocols nationwide as well as reporting of these DAIR procedures to the national joint registry.Methods: All institutions that performed total hip or knee arthroplasty were contacted to complete a 16-question online survey. Questions included availability of a protocol, type and duration of antibiotic prophylaxis used and tendency to register infectious complications in the Dutch Arthroplasty Register.Results: All ninety-nine consulted institutions responded to this survey. All but one institutions have a standardized hospital based protocol for antibiotic prophylaxis in primary total hip or knee arthroplasty. Cefazolin was antibiotic prophylaxis of choice in ninety-four institutions for both primary hip and knee arthroplasty. In ten institutions one preoperative gift of antibiotic prophylaxis was administered. A protocol describing treatment when suspecting early periprosthetic joint infection was present in seventy-one institutions. When performing a DAIR procedure modular parts were exchanged in seventy institutions in case of a hip prosthesis and in eighty-one institutions in case of a knee prosthesis. Sixty-three institutions register DAIR procedures in the Dutch Arthroplasty Register.Interpretation: In contradiction to the results of a recent study in Great Britain, we have found only little variety in availability of protocols and in the type of antibiotic used as prophylaxis in primary total hip and knee arthroplasty in The Netherlands. Not every institution has a protocol for treatment in suspicion of early infection. Although mobile parts are exchanged in the majority of cases, there appears to be an underreporting of DAIR procedures in the Dutch Arthroplasty Register.

A case of complicated lateral subtalar dislocation is presented and the literature concerning this injury is reviewed. Subtalar joint dislocations are rare and often the result of a high-energy trauma. Complications include avascular necrosis of the talus, infection, posttraumatic osteoarthritis requiring arthrodesis and chronic subtalar instability. Negative prognostic factors include lateral and complicated dislocations, total talar extrusions, and associated fractures. A literature search was performed to identify studies describing outcome after lateral subtalar joint dislocation. Eight studies including fifty patients could be included, thirty out of 50 patients suffered a complicated injury. Mean follow-up was fifty-five months. Ankle function was reported as good in all patients with closed lateral subtalar dislocation. Thirteen out of thirty patients with complicated lateral subtalar joint dislocation developed a complication. Avascular necrosis was present in nine patients with complicated injury. Four patients with complicated lateral subtalar dislocation suffered deep infection requiring treatment with antibiotics. In case of uncomplicated lateral subtalar joint dislocation, excellent functional outcome after closed reduction and immobilization can be expected. In case of complicated lateral subtalar joint dislocation immediate reduction, wound debridement and if necessary (external) stabilisation are critical. Up to fifty percent of patients suffering complicated injury are at risk of developing complications such as avascular talar necrosis and infection.

Background 2-stage revision with the use of an antibiotic-loaded interval spacer is therapy of choice in late periprosthetic joint infection for most surgeons. For the spacer, either a prefabricated, functional articulating or custom-made spacer can be used. Little is known about which type of spacer provides optimal outcome after 2-stage revision. The aim of this study was to determine which type of spacer provides the best results, when used in 2-stage revision of an infected THA. Methods We performed a systematic review of the literature to analyse which type of interval spacer provides highest infection eradication rate and best functional outcome after a minimum 2 year follow-up. Exclusion criteria were follow-up of less than 2 years, single-stage revision, or 2-stage revision without use of a spacer. Results 25 studies were included. Infection eradication rate was similar with rates of 96%, 93% and 95% for the prefabricated-, functional articulating- and custom-made spacers respectively. Functional outcome was scarcely described. Postoperative HHS was 81, 90 and 83 respectively. Conclusions Functional articulating spacers achieve a comparable rate of infection eradication in the treatment of periprosthetic hip joint infections as compared to preformed or custom-made antibiotic-loaded spacers. There is insufficient evidence concerning rehabilitation and functional outcome after 2-stage revision hip arthroplasty to advocate or discourage the use of either kind of interval spacer.

Background: Despite the expanding body of literature on radial head arthroplasty, the increasing understanding of elbow anatomy, biomechanics, and kinetics, and the evolution of surgical techniques and prosthesis designs, there is currently no evidence to support one type of radial head prosthesis over another. The purposes of the present report were to review the literature and to explore the association between prosthesis design variables and the timing of surgery and the outcome of modern radial head arthroplasty. Methods: The literature search was limited to studies involving skeletally mature patients. Major databases were searched from January 1940 to May 2015 to identify studies relating to functional and subjective outcomes and radiographic results after radial head arthroplasty. Results: Thirty articles involving 727 patients were included. Seventy percent of the implants were made of cobalt-chromium, 15% were made of pyrocarbon, 9% were made of titanium, and 6% were made of Vitallium. Seventy percent were monopolar, and 30% were bipolar. Twenty-one percent were cemented in place, 32% were press-fit, 32% were intentionally loose-fit, and 15% were fixed with an expandable stem. The weighted average duration of follow-up was 45 months. The rate of revision ranged from 0% to 29% among studies. The incidence of revision was 8% during 2,714 person-years of follow-up across all 727 patients, yielding a crude overall revision rate of 2.06 per 100 person-years of follow-up. The revision rate was not significantly affected by prosthesis polarity, material, or fixation technique, nor was it significantly affected by the delay of treatment. There was also no significant effect of prosthesis polarity, material, or fixation technique on postoperative range of motion. The Mayo Elbow Performance Score was only reported for half of the overall patient population, but, among those patients, the combined rate of excellent and good results was 85%. Seven percent of the overall patient population underwent secondary surgery about the elbow other than revision surgery. Twenty-three percent were reported to have 1 or more complications. Conclusions: On the basis of our analysis of the peer-reviewed English-language literature on radial head arthroplasty from January 1940 to May 2015, there seems to be no evidence to support one type of radial head prosthesis over another. The only exception is that silicone prostheses have been shown to be biologically and biomechanically insufficient. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Severe extra-articular deformities can be treated with single-stage total knee replacement (TKA) and osteotomy. Aim of this study was to examine the patient-reported outcome measures (PROMs) and the complications after single-stage TKA and osteotomy. We hypothesized patients achieve good outcome after single-stage TKA and osteotomy, which is comparable to outcome after primary TKA without deformity. Twenty-one patients with severe extra-articular deformity who underwent single-stage TKA and deformity-correcting osteotomy were reviewed and invited to fill in PROMs including the Oxford Knee Score, the Short Form-12, a Visual Analogue Scale for pain, and questions about satisfaction and quality of life. The mean follow-up period was 64 months. Ten patients were treated with TKA and supracondylar femoral osteotomy. Although PROMs showed good results (mean quality of life score was 85 out of 100), two patients had a revision of the osteotomy due to non-union. Eleven patients were treated with TKA and high tibial osteotomy. Patients were satisfied with the results (mean quality of life score was 81 out of 100). Two patients developed infection requiring debridement, resulting in one arthrodesis and one gastrocnemius transfer for wound closure. In general, patients were satisfied with the postoperative result. Outcome was comparable to patients after primary TKA in the literature. However, serious complications need to be taken into account. III.