Excision Arthroplasty Research Articles

Septic arthritis of the hip after percutaneous coronary intervention: A rare and morbid complication

Infective complications of cardiac catheterization have come down significantly in the past few decades but are occasionally reported. We report one such complication in an elderly female who developed septic arthritis of the hip due to Staphylococcus aureus infection following percutaneous coronary intervention through right femoral access. After an initial conservative strategy with girdlestone excision arthroplasty, she underwent a total hip replacement surgery as a staged procedure after the complete resolution of infection. With the increasing usage of femoral vascular access and vascular closure devices for various complex cardiac interventions in the present-day cardiac catheterization laboratory, a morbid complication like septic hip arthritis should be borne in mind whenever a patient presents with fever and hip joint pain, particularly when there are disproportionate or no significant local findings. Strict aseptic precautions, early identification by considering a magnetic resonance imaging scan early in the clinical course, and aggressive management are the key to better outcomes.

Should we offer total hip replacement to feline patients?

PICO question
 In cats with traumatic coxofemoral injury, does total hip replacement (THR) offer improved outcome when compared with femoral head and neck excision (FHNE) arthroplasty?
 
 Clinical bottom line
 Category of research question
 Treatment
 The number and type of study designs reviewed
 One paper was critically reviewed. It was a non-randomised retrospective observational study
 Strength of evidence
 Moderate evidence
 Outcomes reported
 THR results in superior clinical outcome and owner satisfaction compared to FHNE in cats
 Conclusion
 In cats with traumatic coxofemoral injury, although the evidence is not conclusive and somewhat limited, the literature reviewed here suggests that THR offers a superior outcome in feline patients.
 There is currently insufficient evidence to determine if there is a difference in long-term outcome, complications or osteoarthritis (OA) development following THR or FHNE in feline patients
 
 How to apply this evidence in practice
 The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.
 Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.
 

Outcome of Neglected Elbow Dislocation Treated with Open Reduction at Rural Tertiary Care Hospital in Nepal.

Chronic unreduced dislocation of elbow is a rare injury. Treatment options include open reduction internal fixation with K wire, replacement arthroplasty, excisional arthroplasty, arthrodesis, and hinged external fixator. The aim of this study is to determine the outcome of open reduction internal fixation with trans-olecranon K wire for neglected elbow dislocation. This is a retrospective study done in three rural hospital of Karnali. Hospital records were reviewed from July 2015 to May 2018 to identify 11 cases who underwent open reduction internal fixation for neglected elbow dislocation. Pre and Postoperative outcome was assessed using range of motion and Mayo Elbow Performance Index. Data analysis was done using SPSS version 17. The average age of patient was 22.7 years (range 9-50 years). Non dominant hand was involved in 54.55%. The average preoperative elbow extension was 5.9 degree whereas postoperative extension was 15.9 degree. The average preoperative and postoperative elbow flexion was 24.5? and 113.6? respectively. Preoperative and postoperative Mayo elbow performance index was 18.6 and 86.3 respectively. Outcome was excellent in four patients, good in five patients and fair in two patients with one case having superficial infection. Open reduction and internal fixation with trans-olecranon k wire is an effective treatment method for neglected elbow dislocation. Postoperatively, elbow function is better with minimal complications.

A cohort study comparing internal fixation for undisplaced versus hip arthroplasty for displaced femoral neck fracture in the elderly: a pilot study for a clinical trial

IntroductionThe literature regarding undisplaced femoral neck fractures (FNF) is sparse. The aim of this prospective feasibility study is to compare the clinical outcome after undisplaced FNF treated with internal fixation (IF) and displaced FNF treated with hip arthroplasty. We hypothesized that hip arthroplasty would give a lower incidence of reoperations.MethodsA total of 235 patients were included with a median age of 84 years (range 65–99). A consecutive series of 65 patients with undisplaced FNF were treated with IF, and 170 patients with displaced FNF were treated with either a total hip arthroplasty or a hemiarthroplasty. Follow-up interviews were conducted at 1 year using the Harris Hip Score (HHS), WOMAC, and pain numeric rating scale (PNRS). The minimum follow-up time was 22 months. There was no difference in baseline data between the groups.ResultsNineteen (8%) hips required reoperation at least once at a mean of 6 months (range 0–35). The rate of reoperation was higher in the IF group compared to the hip arthroplasty group (13.8% vs. 5.9%, 95% CI 0.9–6.4). The overall 1-year and 2-year mortality was 28% and 40%, respectively, with no difference between the groups. The most common reasons for reoperations in the IF group were non-union and avascular necrosis, and 6 patients were treated with hip or excision arthroplasty. In the arthroplasty group, the most common indications were deep infection and dislocation. We did not find any differences between the groups in terms of HHS, WOMAC, and PNRS.ConclusionsIn this feasibility study, we found no differences in patient-reported outcomes between the groups although IF required a higher rate of reoperations. Further randomized trials are needed to establish the optimal treatment of undisplaced FNF in the elderly.Trial registrationClinicalTrial.org, NCT03392285. Retrospectively registered on 5 February 2018.

Patient-Reported Outcomes of Femoral Head Fractures with a Minimum 10-Year Follow-Up.

To evaluate the clinical-reported and patient-reported outcomes of patients with femoral head fractures treated at a single level I trauma center with a minimum 10-year follow-up. Retrospective review. Academic Level-1 Trauma Center. One hundred one consecutive femoral head fractures were identified for this study. The final study group consisted of 28 patients with a minimum of 10 years of clinical follow-up. All patients were treated with one or in combination with the following treatments: nonoperative management, open reduction and internal fixation, fragment excision, or total hip arthroplasty (THA). The Oxford Hip Score (OHS) at final follow-up along with clinical and radiological complications: infection, avascular necrosis, post-traumatic osteoarthritis, heterotopic ossification, and conversion to THA. Twenty-eight patients with greater than 10 years of follow-up were included in this evaluation. The average follow-up was 14 years, and the average age was 39.2 years. Surgical management occurred in 86% of patients, and the mean time to definitive treatment was 3.7 days. Overall, 21 patients (75%) experienced a complication. Seven patients (30%) were later converted to a THA at an average of 6.4 years from initial injury. Three of the 7 late THA conversions (43%) required later revision. OHSs were obtained in all 28 patients at the final follow-up. The average OHS was 36.6. The mean OHS of the native hips was 37 at an average follow-up of 13.6 years. The mean OHS of primary THA was 41, and the mean OHS of secondary THA at final follow-up was 31.4, but this was not statistically significant (P = 0.134). Patients should be counseled that the long-term results of open reduction and internal fixation may be satisfactory but unfortunately are not predictable. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Varisized 3D-Printed Lunate for Kienböck's Disease in Different Stages: Preliminary Results.

ObjectiveTo evaluate the feasibility of arthroplasty with varisized three‐dimensional(3D) printing lunate prosthesis for the treatment of advanced Kienböck's disease (KD).MethodsFrom 2016 November to 2018 September, a retrospective study was performed for the patients of KD in our hospital. Five patients (two males, three females) were included in this study. The mean age of the patients at the time of surgery was 51.6 years (range, 37–64 years). Varisized prosthesis identical to the live model in a ratio of 1:0.85, 1:1, and 1:1.1 were fabricated by 3D printing. All patients (one in Lichtman IIIA stage, two in Lichtman IIIB stage, one in Lichtman IIIC stage, and one in Lichtman IV stage) were treated with lunate excision and 3D printing prosthetic arthroplasty. Visual analog scale score (VAS), the active movement of wrist (extension, flexion) and strength were assessed preoperatively and postoperatively. The Mayo Modified Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) Score, and patient's satisfaction were evaluated during the follow‐up.ResultsProsthesis identical to the live model in a ratio of 1:0.85 or 1:1 were chosen for arthroplasty. The mean operation time (range, 45 to 56 min) was 51.8 ± 4.44 min. Follow‐up time ranged from 11 months to 33 months with the mean value of 19.4 months. The mean extension range of the wrist significantly increased from preoperative 44° ± 9.6° to postoperative 60° ± 3.5° (P < 0.05). The mean flexion range of the wrist significantly increased from preoperative 40° ± 10.6° to postoperative 51° ± 6.5° (P < 0.05). The active movement of wrist and strength were improved significantly in all patients. VAS was significantly reduced from 7.3 preoperatively to 0.2 at the follow‐up visit (P < 0.05). The mean DASH score was 10 (range, 7.2–14.2), and the mean MMWS was 79 (range, 70–90). There were no incision infection. All patients were satisfied with the treatment.ConclusionsFor patients suffering advanced Kienböck's disease, lunate excision followed by 3D printing prosthetic arthroplasty can reconstruct the anatomical structure of the carpal tunnel, alleviate pain, and improve wrist movement.

Functional outcome in giant cell tumor of distal radius treated with excision and fibular arthroplasty: a case series.

Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a wide spectrum of biological activity ranging from latent benign to highly recurrent and has occasional metastatic potential. It affects the meta-epiphyseal region of long bones of young adults with most common site involved is the distal femur, followed by the distal radius. Plain radiographs and contrast-enhanced magnetic resonance imaging are the imaging modalities widely used followed by definite histopathology for diagnosis. Surgical treatment with curettage is considered optimal for local tumor control. Tumor excision with tumor-free margins is associated with lesser recurrence rates; however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome. Eleven eligible patients (all females, mean age 39.2years) with Campanacci grade III GCT of the distal radius who were treated by en bloc resection and reconstruction with non-vascularized proximal fibular autografts at a single centre between July 2016 and December 2017 were included in the study. The patients had a clinical and radiographic review every month for the first 6months, then biannually for minimum of 2years. The functional, oncologic and radiological outcomes of the patients were analyzed and recorded. The mean duration of follow-up was 31.9months. Bony union was achieved in all cases. The mean VAS score at 6months was 1.1 (range 0-2). The mean Mayo Wrist score was 66.36 (range 55-80) with mean MSTS score was 21.09 (range 18-24). The average range of motion of the wrist was: 37.3° ± 6.9° of flexion, 47.1° ± 7.5° of extension, 57.3° ± 7.8° of supination and 63.6° ± 6.4° of pronation. The average graft length used was 15.6cm. The complications noted were lung metastases which developed preoperatively, local site recurrence, wrist joint subluxation, foot drop and wound complication. The primary aim of treating GCT distal radius is oncologically sound resection with good functional outcome and cosmesis being secondary. Reconstruction with a non-vascularized proximal fibular autograft is a reasonable option after en bloc resection of the distal radius for giant cell tumor of bone having comparable results with other treatment modalities.

Is This Rapid Destructive Hip Osteoarthritis ?

Rapid destructive hip osteoarthritis is a diagnosis by exclusion. It should be differentiated from septic arthritis, osteonecrosis, neuropathic arthritis and other aetiologies causing rapid bone resorption or destruction around the hip. The present study aims to review the incidence of rapid destructive hip osteoarthritis among those patients who request total hip arthroplasty for end stage arthrosis.A retrospective review of radiographs of all patients who scheduled for total hip arthroplasty from January 2010 to March 2019 were analysed by 3 orthopaedic fellows. Of 174 hips of 146 patients, 35 hips of 29 patients were considered by at least 2 orthopaedic fellows to have rapid destructive hip osteoarthritis based on radiographic criteria of rapid joint space narrowing or rapid destruction of femoral head with or without acetabular involvement. Clinical history and physical finding, blood biochemistry, cultures and pathology with or without frozen section are reviewed.Early total hip arthroplasty, rather than routine operation in the long waiting list, is recommended for rapid destructive hip osteoarthritis to prevent technical difficulty in dealing with the bone loss or defect associated with rapid destructive hip osteoarthritis. However, one must exclude septic arthritis before proceeding to total hip arthroplasty. In clinically highly suspected cases, staged total hip arthroplasty was done despite of normal initial blood investigationsand negative hip aspiration with equivocal frozen section on table. In one such patient, the culture was initially negative, but became positive only after extended period of culture. On the other hand, rapid destruction of acetabulum requiring impaction bone grafting and acetabular augmentation for total hip arthroplasty was needed in one patient. Malignancy was suspected in another patient, but there was no evidence of malignancy or infection in the femoral head and tissue obtained by excisional arthroplasty of hip. One patient with hip pain and bilateral hip involvement was found to have Charcot joint.Rapid destruction hip osteoarthritis represents an uncommon subset of arthrosis with rapid progression. A delicate balance between correct diagnosis and timely early operation should be exercised to prevent rapid loss of bone stock making delayed total hip arthroplasty become technical difficult with possible compromised outcomes.

Early Peri-Prosthetic Joint Infection after Hemiarthroplasty for Hip Fracture: Outcomes of Debridement, Antibiotics, and Implant Retention.

Background: There are currently no treatment algorithms specifically for early peri-prosthetic joint infection (PJI) after hemiarthroplasty for hip fracture. Commonly, debridement, antibiotics, and implant retention (DAIR) is attempted as first-line management, despite lack of evidence supporting this strategy in this patient group. The purpose of this study was to evaluate outcomes of DAIR for early PJI after hemiarthroplasty for hip fracture in our unit. Methods: The departmental database from December 2008 to January 2019 was searched to identify all patients in our unit who were treated for early PJI after hemiarthroplasty for hip fracture. Data for included patients were collected from electronic healthcare records and analyzed. Primary outcome measure was treatment success, defined as patient survival to discharge, with eradication of infection and implant retention. Results: Twenty-six patients were identified and included in the study. Mean age was 84.7 years. All except one patient were American Society of Anesthesiologists (ASA) class 3 or 4. All patients were McPherson host grade B or C. Twenty-three of 26 patients underwent DAIR and three of 26 proceeded directly to excision arthroplasty. Debridement, antibiotics, and implant retention was successful in three of 23 patients (13%) after a single procedure, with success in two additional patients after a second procedure, giving overall success rate of five of 23 patients (22%). Conclusions: Debridement, antibiotics, and implant retention has a high failure rate in treating early PJI after hemiarthroplasty for hip fracture. These patients are generally elderly and frail with multiple host and wound compromising factors. Debridement, antibiotics, and implant retention should not be recommended as first-line management for the majority of these patients, for whom getting it right the first time is of vital importance to avoid consequences associated with failed surgical procedures. Further multicenter studies that also explore alternate treatment strategies are required to devise an algorithm specifically for hip fracture patients, to aid decisions on treatment and improve outcomes.

Ulnar Cortical Window for Removal of a Well-Fixed Ulnar Component in Total Elbow Arthroplasty: Surgical Technique and Case Report

Infection after total elbow arthroplasty can be a devastating problem. Eradication of the infection can often be difficult and may compromise the already tenuous bone and soft tissue, particularly the elbow extensor mechanism. Resection arthroplasty with the complete removal of all foreign material is often necessary to adequately treat the infection. Components may be well fixed and removal may further compromise bone and soft tissue. The authors present a technique of ulnar cortical window that facilitates the removal of a well-fixed ulnar component and the associated cement mantle. An illustrative surgical case is also included with pertinent intraoperative and radiographic images. This technique provides reliable, atraumatic access to the ulnar canal, cement mantle, and component for safe extraction of a well-fixed implant. When comparing with other techniques in the removal of the ulnar component, such as transverse ulnar osteotomy, and extended olecranon osteotomy, our technique did not breach the bony integrity of ulna, and it did not require wiring for rigid fixation of the bony fragment. This may be more applicable in excisional arthroplasty for the management of infected total elbow arthroplasty.

Radial head excision and Achilles allograft interposition arthroplasty for the treatment of chronic pediatric radiocapitellar pathologies: A report of four cases.

Severe radiocapitellar pathologies represent a unique problem in the pediatric population, as radial head excision can lead to substantial long-term complications. We present a case series of four pediatric patients treated by a novel technique-radial head excision followed by Achilles allograft interposition arthroplasty. Four children (ages 12-15 years) are described. Their clinical and radiographic outcomes were assessed by a visual analog scale, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder and Hand questionnaire, grip strength, and range of motion. At a mean follow-up of two years, the average flexion-extension arc of motion improved from 107° to 131°, and the rotation arc improved from 100° to 154°. The average visual analog scale, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand scores were 2, 92.5, and 11.5, respectively. Two patients required subsequent additional procedures-manipulation under anesthesia and ulnar shortening osteotomy. Proximal migration of the radius was observed in three out of the four patients. Combined radial head excision and Achilles allograft interposition arthroplasty represents a viable option for the treatment of chronic pediatric radiocapitellar pathologies, with good results in terms of clinical and functional outcomes as well as patient satisfaction in the short-medium term.

Extra-articular resection of shoulder joint for bone sarcomas: Oncologic and limb-salvage outcomes of 32 cases compared with shoulder disarticulation and forequarter amputation.

We aimed to identify the overall survival (OS), surgical complications, survival of reconstruction, and functional outcome of patients who underwent extra-articular resection of the shoulder joint for primary bone sarcomas. The OS and local recurrence rates in patients who underwent an amputation were also evaluated for comparison. Thirty-two patients treated between 1988 and 2017 were studied. The tumours were located in the humerus in 22 (69%) and scapula in 10 patients (31%). The resection types were Malawer type IV in 6 (19%), type V in 21 (66%), and type VI in 5 patients (15%). Reconstruction was performed with endoprosthesis in 23 patients (72%) while excision arthroplasty with the suspension of the humerus to the clavicle was performed in 9 patients (28%). Surgical margins were wide in 16, marginal in 8, intralesional in 3, and not available in 5 patients. During the study period, 40 patients underwent a forequarter amputation and 11 patients underwent a shoulder disarticulation. The 5-year OS for patients who underwent extra-articular resection of the shoulder joint was 42% which was not statistically different compared with that of patients who underwent amputation (5-year OS = 30%; P = .091). The 5-year survival of the reconstruction was 94%, similar for endoprosthesis and excision arthroplasty. Local recurrence and complications developed in 6 (19%) and 10 patients (31%), respectively. Failures of the reconstruction requiring revision surgery occurred in two patients (6%). Limb salvage was achieved in 30 patients (94%). The median Musculoskeletal Tumour Society functional score was 61% (interquartile range, 57%-70%) and was similar in the endoprosthesis and excision arthroplasty group. Extra-articular resection of the shoulder joint for bone sarcomas is an effective limb-salvage method. However, local recurrence remains a principal concern.

Kienbock’s disease-avascular necrosis of lunate operated with excisional arthroplasty and Palmaris longus graft interposition

Kienbock’s disease-avascular necrosis of lunate operated with excisional arthroplasty and Palmaris longus graft interposition

Challenges in primary hip arthroplasty for neglected post-traumatic hip dislocations with acetabular defect

Primary hip arthroplasty in the presence of acetabular defect seen in patients with neglected post-traumatic hip dislocation is quite challenging due to the need in securing stability of hemispherical cup and providing enough rigid fixation needed to prevent acetabular cup micromotion. In segmental acetabular defect, contained or uncontained, there is an acetabular rim violation, an important risk factor for cup micromotion, loosening in the long term and subsequent failure. In our environment, most of the patients with post-traumatic hip dislocation present late, making conservative management (closed reduction and traction) or primary acetabular restorative reconstruction very difficult, hence the surgeon is left with the option of either Girdlestone excision arthroplasty, arthrodesis, hemiarthroplasty or total hip replacement. For the few who present early, most of them may not afford the cost of surgery (total hip replacement) and majority of centres in developing countries do not have facilities and trained personnel to handle such complex procedures. Impaction of cancellous bone graft to the acetabular defect is a common practice among arthroplasty surgeons. This, however, does not guarantee bony ingrowth at cup/graft interface and initial rigid fixation. The resultant acetabular cup micromotion on commencing weight-bearing would affect biologic fixation and may explain the relatively high incidence of loosening in this category. It is with this background that we review this important topic in hip arthroplasty highlighting various options of treatments, outcomes and recommendations.

Arthroscopic Excision Arthroplasty of the Sternoclavicular Joint for Osteoarthritis: A Case Series of 50 Patients

to report the results of a consecutive series of 50 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for primary osteoarthritis refractory to conservative treatment. We undertook an arthroscopic excision of the SCJ in 50 patients with primary osteoarthritis refractory to conservative treatment. This included an adequate course of physiotherapy and at least 1 ultrasound-guided cortisone injection. There were 26 female and 24 male patients and the mean age at the time of surgery was 54.5 years (range 39-72 years). Patients were assessed preoperatively and at final follow-up with the Constant, Rockwood SCJ, and Quick-DASH scores. The mean follow-up was 41.8 months (range 24-73 months). Surgery was undertaken as a day-case with no shoulder immobilization. Forty-five patients were available at final-follow up. The median Constant score had increased from 55 (range 37-79) to 72 (range 38-92), Rockwood score from 6 (range 4-9) to 13 (range 4-15), and Quick-DASH 36 (range 18-69) to 12 (range 0-51). All of these changes were statistically significant (P < .0001). There were no complications and, specifically, no problems with joint instability. Forty-four of the 45 patients were pleased with the results of their surgery and indicated that they would be happy to have the procedure again. The results of this study show that arthroscopic excision arthroplasty of the SCJ is a satisfactory treatment for primary SCJ osteoarthritis refractory to conservative treatment. Level IV case series.

Comparison of arthrodesis and arthroplasty in patients with thumb carpometacarpal osteoarthritis

Objective To compare the effect of arthrodesis and arthroplasty in patients with thumb carpometacarpal osteoarthritis, and to compare the advantages and disadvantages of the two methods. Methods From February 2012 to September 2017, 39 patients with phases Ⅱ and Ⅲ thumb carpometacarpal osteoarthritis underwent surgical treatment. 22 cases were performed with trapeziometacarpal arthrodesis and 17 cases were performed with trapezial excision arthroplasty with ligament reconstruction and tendon interposition (LRTI). Postoperatively, objective and subjective evaluation were performed on the two groups, respectively. The objective evaluation included grip strength, pinch strength, thumb abduction degree (palmer and radial), Kapandji opposition score. The subjective evaluation included visual analogue scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH) score. The data of the two methods were compared and their differences were observed. Results In the comparison between arthrodesis and arthroplasty group, the differences of pinch strength, thumb abduction degree (palmer and radial), Kapandji opposition score were obvious, but there was no significant difference in grip strength, VAS and DASH score. Conclusion For patients with progressive thumb carpometacarpal osteoarthritis, carpometacarpal arthroplasty or arthroplasty can significantly relieve joint pain and improve grip strength. Arthrodesis can improve thumb pinch strength better, while arthroplasty can improve thumb mobility better. The patients are consciously satisfied with the effects of the two surgical methods. Key words: Thumb; Carpometacarpal joints; Arthrodesis; Arthroplasty

Mesenchymal Stem Cell Treatment of Osteoarthritis.

Treatment of canine osteoarthritis comprises a large part of the clinical practice of small animal surgeons. Some cases are post-traumatic, but most are heritable, developmental or idiopathic in origin. Although the pathological changes of osteoarthritic joints are essentially irreversible, many types of surgical procedures are aimed at restoring mobility, including prosthetic joint replacement, joint resurfacing, osteotomy, arthrodesis and excision arthroplasty. However, for a very large cohort of dogs suffering from osteoarthritis, surgical treatment of osteoarthritis is not indicated, not appropriate, not feasible or not affordable. Consequently, the search for effective non-surgical treatments such as systemic and intra-articular medications and other modalities is a critical priority. Considering that intractably painful osteoarthritis is a frequent reason for poor quality of life and even euthanasia, this is indeed an appropriate priority.

Continuing acromioclavicular joint pain after excision arthroplasty: is further surgery effective?

Little published evidence exists on the incidence of continuing acromioclavicular joint pain with no published outcomes for revision surgery. This study aimed to establish the incidence and outcomes of revision acromioclavicular joint excision surgery. A consecutive retrospective cohort of patients undergoing revision arthroscopic or open acromioclavicular joint excision was identified. Patients were identified from a prospectively collected database. Inclusion criteria were revision acromioclavicular joint excisions over a 14-year period between 2001 and 2015. Exclusion criteria were previous surgery for acromioclavicular joint instability or shoulder arthroplasty. Outcome measures were Oxford Shoulder scores and a satisfaction survey. Forty-three consecutive cases of revision acromioclavicular joint excision over 14 years (37 after arthroscopic excision with subacromial decompression, 5 after arthroscopic excision with rotator cuff repair, 1 after open excision). Continuing acromioclavicular joint pain was associated with incomplete resection from arthroscopic surgery, which was the primary indication for revision surgery. Revision occurred a mean 14.2 months after primary surgery (standard deviation 7.6 months). Mean Oxford Shoulder score was preoperatively 18 (standard deviation 8.1) and 23.4 (standard deviation 11.1) after primary surgery, which did not reach significance until after revision surgery with a mean 31.7 (standard deviation 13.6; P = 0.021). Median follow up was 15 months (interquartile range 4-31 months). A survey at a mean of 6 years (standard deviation 2.3) post-revision surgery found that 65% of patients felt improved, 77% would have their surgery again and 69% of patients felt satisfied. The incidence of postoperative frozen shoulder was 14.3%. Functional outcomes after revision surgery showed improvement from scores taken before primary surgery; however, long-term satisfaction rates were relatively low.

Does indication matter in the functional outcome of reverse shoulder arthroplasty? - A comparative retrospective study

Reverse Shoulder Arthroplasty is done for Cuff Tear Arthropathy (CTA) and other indications. We hypothesize that CTA patients and patients with other indications will have differing functional outcome following RSA. We retrospectively studied 23 patients treated in our center between 2014 and 2017. The patients who were aged 60 and above with normal Deltoid function, normal cognition and a minimum follow-up of 12 months were included. Of the 23 patients, 16 had CTA and 7 had either a complex fracture dislocation, arthritis with malunion, excision arthroplasty or a chronic dislocation. We compared the functional outcome using Constant Shoulder Score at a mean follow up of 24.6 months. The post-operative scores were significantly higher in the CTA group, but the magnitude of functional improvement from preoperative status following RSA was either comparable (absolute change) or even better (percentage change) in non-CTA patients compared to CTA patients. There were no significant differences in the complication rates between the two groups. We conclude that one should not be discouraged by the lower values of functional scores in RSA done for non-CTA indications and be aware that the functional improvement following RSA in such complex cases is encouragingly better than that following RSA in CTA.

Epidemiological and clinical features of prosthetic joint infections caused by gram-negative bacteria.

To review the clinical literature focusing on epidemiology, clinical presentation and outcomes of prosthetic joint infections (PJIs) due to gram-negative bacteria (GNB) and to report the experience of a multicentric cohort. A retrospective, observational, cohort study was performed in three Italian hospitals. All consecutive PJIs caused by GNB over a 12-year period (from May 2007 to March 2018) were enrolled. Epidemiological, clinical, microbiological and therapeutic features were described. Factors related to treatment failure (defined as the occurrence of death, amputation or starting long-term antimicrobial suppression therapy) were analysed with a Cox regression model. A total of 82 PJIs due to GNB (42.7% men; median age 73 years) were studied. The implants included 65 (79.3%) hip, 16 (19.5%) knee and one (1.2%) shoulder. An early PJI was diagnosed in 16.2% of patients, a delayed PJI in 29.4% and a late PJI in 54.4%. The most common isolated organisms were Escherichia coli (21.7%) and Pseudomonas spp. (20.9%). 13.4% of the isolates were carbapenem-resistant bacteria (CRB). In 53.8% of cases a two-stage exchange arthroplasty was performed and in 32.5% a Girdlestone excision arthroplasty. The average therapeutic failure occurred in 17.7% of cases. The therapeutic failure rate of the two-stage was 10%. PJI due to CRB was identified as a potential risk factor for failure (aHR 4.90; IC 95%, 0.96-25.08; p=0.05). The therapeutic failure rate in the CRB group was 50%. The treatment with the two-stage procedure for PJIs caused by GNB seems to be associated with a low rate of failure, while PJI due to CRB seems to be related to the worst outcome.