Revision Arthroplasty For Aseptic Loosening Research Articles

Diabetes mellitus is a potential risk factor for aseptic loosening around hip and knee arthroplasty

BackgroundAseptic loosening is a leading cause of revision following total hip and knee arthroplasty which is caused by chronic inflammation around the prosthesis. Diabetes mellitus causes systemic inflammatory changes which could increase the risk of aseptic loosening. This study investigated the association between diabetes mellitus and aseptic loosening around hip and knee arthroplasty.MethodsA case-control study was conducted at a single arthroplasty centre over the seven-year period of January 2015 to December 2021. Cases were defined as any adult patient undergoing revision hip or knee arthroplasty for aseptic loosening. Controls were randomly selected patients undergoing primary total hip or knee arthroplasty during the same period at a 1:4 ratio. Risk factors were compared between the two groups.ResultsA total of 440 patients were included in our study – 88 in the aseptic loosening group and 352 patients in the control group. The odds of having diabetes mellitus in the aseptic loosening group was 2.78 (95%CI 1.31–5.92, P = 0.01). Other risk factors were not significantly different between the two groups.ConclusionsThe incidence of diabetes mellitus is significantly greater in patients undergoing revision arthroplasty for aseptic loosening. Further research is required to explore whether this association is indeed causative.

Drilling the cement mantle in well-fixed periprosthetic femur fractures is not associated with arthroplasty-related complications.

To determine if screw fixation across a cement mantle is safe and effective during plate fixation of well-fixed periprosthetic femur fractures. Retrospective cohort study. Academic Level I Trauma Center. Twenty-eight patients with AO/OTA 32A[B1] or 32A[C] periprosthetic femur fractures treated with open reduction and internal plate and screw fixation after cemented or uncemented hip arthroplasty. Screw placement into the cement mantle during internal fixation. Primary outcome was revision arthroplasty for aseptic loosening. Secondary outcomes included radiographic evidence of aseptic loosening, infection, nonunion, implant failure, and overall reoperation rate. There were 28 patients who met inclusion criteria. A total of 9 patients had screws placed in the cement mantle while the remaining 19 patients had screws placed around an uncemented stem. At a mean of 3.7-year follow-up, there were no cases of revision arthroplasty or aseptic loosening in either group. There were no significant differences in rates of infection, nonunion, implant failure, or reoperation rate between patients who had screw placement into a cement mantle vs around an uncemented stem. Drilling into the cement mantle during fixation of a periprosthetic femur fracture around a well-fixed cemented hip stem appears safe and effective. When possible, surgeons can consider bicortical screws around a cemented stem, given the biomechanical advantages over unicortical screw or cerclage fixation. Larger prospective trials confirming the safety of this technique are warranted prior to routine implementation. III.

The poor accuracy of D-dimer for the diagnosis of prosthetic joint infection but its potential usefulness in early postoperative infections following revision arthroplasty for aseptic loosening

BackgroundD-dimer was introduced in 2018 as an alternative biomarker for C-reactive protein (CRP) in the diagnostic of prosthetic joint infection (PJI) criteria of the Musculoskeletal Infection Society. We assessed the accuracy of plasma D-dimer for the diagnosis of early, delayed, and late PJI according to Infectious Diseases Society of America (IDSA) criteria, and whether persistently high levels of D-dimer in cases of aseptic loosening (AL) may be predictive of subsequent implant-related infection.MethodsA prospective study of a consecutive series of 187 revision arthroplasties was performed at a single institution. Septic (n = 39) and aseptic revisions (n = 141) were classified based on IDSA criteria. Preoperative assessment of CRP, erythrocyte sedimentation rate (ESR) and D-dimer was performed. Receiver operating curves were used to determine maximum sensitivity and specificity of the biomarkers. The natural progress of D-dimer for AL cases was followed up either until the date of implant-related infection at any time during the first year or 1 year after revision in patients without failure. Clinical outcomes for those AL cases included infection-related failure that required a new surgery or need for antibiotic suppression.ResultsPreoperative D-dimer level was significantly higher in PJI cases than in AL cases (p = 0.000). The optimal threshold of D-dimer for the diagnosis of PJI was 1167 ng/mL. For overall diagnosis of PJI, C-reactive protein (CRP) achieved the highest sensitivity (84.6%), followed by erythrocyte sedimentation rate (ESR) and D-dimer (82% and 71.8%, respectively). Plasma D-dimer sensitivity was lower for all PJI types. When combinations of 2 tests were studied, the combined use of ESR and CRP achieved the best accuracy for all types of PJI (76.9%). 4.25% of AL cases had implant failure due to implant-related infection during the first year after the index revision arthroplasty, only the cases with early failure maintained high D-dimer levels.ConclusionsPlasma D-dimer did not offer an improvement over the individual or combined diagnosis for any type of PJI according to IDSA criteria. Persistently raised levels of D-dimer after revision arthroplasty in AL cases might be used to effectively diagnose early postoperative infection.

“Unexpected” Infections in Revision Arthroplasty for Aseptic Loosening

Background. Data from the national registers of arthroplasty showed that about 12% of hip and knee arthroplasty undergo revision within 10 years after the primary surgery. The leading cause of hip revisions is aseptic loosening of components, knee joint periprosthetic infection (PPI). Some of the infectious complications, including those related to mechanical causes, remain out of sight. The aim of the study was to identify the frequency of unexpected infections during revision knee and hip arthroplasty performed for aseptic complications of any etiology. Materials and Methods. 839 cases of revision arthroplasty of knee and hip joints were analyzed, including 485 aseptic revisions in 450 patients. Clinical, X-ray, laboratory (complete blood count and comprehensive metabolic panel, coagulation panel) methods, synovial fluid analysis and microbiological examination of punctures, including intraoperative ones, were used. The ICM and EBJIS (European Bone and Joint Infections Society) consensus recommendations were used as criteria for assessing the presence of infection. Results. The average age of patients at the time of the revision was 61.7 years. The hip joint prevailed (59.4%), knee joint 40.6%. The growth of microorganisms in the intraoperative biomaterial was detected in 2.08% of observations: in 10 out of 287 patients after aseptic revision of the hip joints and in none of the 198 revisions of the knee joints. In 8 out of 10 cases, the causative agents were coagulase-negative staphylococci, including 6 MRSE; in two cases, anaerobic bacteria. All revisions were carried out by a one-stage method. Patients with detected PPI underwent systemic antibacterial therapy. At the stage of catamnesis, reinfection was assumed in one of the 10 identified cases of PPI, the patient did not show up for revision. In control 63% of the group of the other (aseptic) 470 patients, PPI developed in 4 cases, two-stage revisions were carried out. Conclusions. The frequency of infections accidentally detected during aseptic revisions of large joints was 2.08%. Three-time examination of joint punctures, including intraoperative, provides additional opportunities for the diagnosis of PPI during aseptic revision, and also allows you to choose the optimal stage of revision treatment. The experience gained makes it possible in certain cases to perform one-stage revision in the treatment of PPI.

Mid-term (5-10 year) Results of the Salto Talaris Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: The Salto Talaris total ankle replacement is a modern fixed-bearing implant used to treat symptomatic ankle arthritis with the goals of providing pain relief, restoring mechanical alignment, and allowing motion of the ankle joint. This prosthesis has been used in the United States increasingly over the last 10 years, primarily for older patients with end-stage ankle arthritis but indications are expanding to younger and more active patients. The goal of this study is to report the midterm clinical results of one of the largest cohort of patients in the United States who underwent ankle replacement with this prosthesis. Methods: This is a review of patients with a minimum of 5-year up to 10-year follow-up who were prospectively registered within our institutional database prior to proceeding with total ankle arthroplasty using the Salto Talaris prosthesis. Follow-up examinations were scheduled annually after the one-year postoperative mark to evaluate patients both clinically and radiographically. At each annual assessment, patients rated their current level of pain using the visual analog score (VAS) and reported their functional level using the American Orthopaedic Foot and Ankle (AOFAS) ankle-hindfoot scores, the Short Musculoskeletal Function Assessment (SMFA), and the Short Form-36 (SF-36) Health survey. These scores were analyzed to assess differences between their levels preoperatively, one year postoperatively and at their most recent follow-up. Preoperative and postoperative radiographs were reviewed for component loosening. Criteria for failure was defined as undergoing revision requiring exchange or removal of the metallic components for any reason. Results: We identified 106 patients who had a Salto Talaris total ankle replacement between March 2007 and February 2012. Of these, 72 patients (mean age, 61.9 years) met the requirement for a minimum follow-up of 5 years (range 60 to 115 months, mean 81.1 months). Average outcome in the VAS was 7.1 at one year post-op and 11.7 at last follow-up (preop: 70.0). Significant improvements were seen in the SMFA, AOFAS ankle-hindfoot score, and the SF-36 from preoperatively to their final follow-up. Survivorship was 97.2% with two patients undergoing revision arthroplasty for aseptic loosening and a third patient scheduled for revision for a chronic wound infection. 14 patients (19%) with midterm follow-up required a total of 17 additional surgical procedures on the ipsilateral ankle or hindfoot. Conclusion: Patients who underwent total ankle arthroplasty with the Salto Talaris prosthesis have continued to show significant improvements in pain and functional outcomes at mid-term follow-up. This has shown to be an effective treatment option with durable results for patients with end-stage ankle arthritis.

26Postoperative diagnosis and outcome in patients with revision arthroplasty for aseptic loosening.

BackgroundThe most common cause of implant failure is aseptic loosening (AL), followed by prosthetic joint infection (PJI). This study evaluates the incidence of PJI among patients operated with suspected AL and whether the diagnosis of PJI was predictive of subsequent implant failure including re-infection, at 2 years of follow up.MethodsPatients undergoing revision hip or knee arthroplasty due to presumed AL from February 2009 to September 2011 were prospectively evaluated. A sonication fluid of prosthesis and tissue samples for microbiology and histopathology at the time of the surgery were collected. Implant failure include recurrent or persistent infection, reoperation for any reason or need for chronic antibiotic suppression.ResultsOf 198 patients with pre-and intraoperative diagnosis of AL, 24 (12.1 %) had postoperative diagnosis of PJI. After a follow up of 31 months (IQR: 21 to 38 months), 9 (37.5 %) of 24 patients in the PJI group had implant failure compared to only 1 (1.1 %) in the 198 of AL group (p < 0.0001). Sensitivity of sonicate fluid culture (>20 CFU) and peri-prosthetic tissue culture were 87.5 % vs 66.7 %, respectively. Specificities were 100 % for both techniques (95 % CI, 97.9–100 %). A greater number of patients with PJI (79.1 %) had previous partial arthroplasty revisions than those patients in the AL group (56.9 %) (p = 0.04). In addition, 5 (55.5 %) patients with PJI and implant failure had more revision arthroplasties during the first year after the last implant placement than those patients with PJI without implant failure (1 patient; 6.7 %) (RR 3.8; 95 % CI 1.4-10.1; p = 0.015). On the other hand, 6 (25 %) patients finally diagnosed of PJI were initially diagnosed of AL in the first year after primary arthroplasty, whereas it was only 16 (9.2 %) patients in the group of true AL (RR 2.7; 95 % CI 1.2–6.1; p = 0.03).ConclusionsMore than one tenth of patients with suspected AL are misdiagnosed PJI. Positive histology and positive peri-implant tissue and sonicate fluid cultures are highly predictive of implant failure in patients with PJI. Patients with greater number of partial hip revisions for a presumed AL had more risk of PJI. Early loosening is more often caused by hidden PJI than late loosening.

Long Stem Cemented Revision Arthroplasty for Aseptic Loosening in Elderly Patients Produces Good Results, despite Significant Bone Loss

We assessed the results of long cemented stems in patients over 65 undergoing a first time revision hip arthroplasty for aseptic loosening. 103 patients were followed up for a minimum of five years after revision surgery; 45% had EndoKlinik C grade preoperative bone loss. At final follow-up 31 patients had died, all but one with the prosthesis in situ. There were 71 revisions alive, one had been revised for a peri-prosthetic fracture. Of the 45 that had radiographs at a minimum of five years, three stems were probably or definitely loose according to the Harris classification. There was 92% patient satisfaction and a mean Oxford Hip Score (OHS) of 25/60 in the 59 patients that had not been revised and had full clinical follow-up. Long-stem cemented revisions for aseptic loosening in elderly patients allow immediate postoperative weight bearing and have good radiological and clinical outcomes.

Relationship between the degree of osteolysis and cultures obtained by sonication of the prostheses in patients with aseptic loosening of a hip or knee arthroplasty

The pathogenesis of prosthesis loosening is not well understood. The aim of our study was to sonicate components of joint prostheses removed due to aseptic loosening, culture the sonicate fluid, and to correlate these results with the degree of radiological osteolysis. From January 2008 to June 2009 all consecutive patients who underwent a revision of hip or knee prosthesis due to aseptic loosening were included in the study. Aseptic loosening was established when the patient had radiological signs of loosening without symptoms or signs of infection. The diagnosis was confirmed when histology was negative, and ≥ 5 out of 6 standard cultures of periprosthetic tissue were negative. Bone lysis was measured according to the Paprosky or Engh classifications without knowing the result of sonication cultures. Removed components were placed in sterile bags and immediately transported to the microbiology laboratory and sonicated. Sonicate fluid was cultured and the results were correlated with the degree of bone lysis. The proportion of components with positive sonication culture according to the bone lysis classification was compared using χ(2) test. A total of 52 patients were included and 123 components were sonicated. In 30 patients at least 1 sonicated component was positive (57.7%) and 44 out of 123 (35.8%) components were positive. The proportion of positive sonication cultures was significantly higher in the group of components with a higher degree of bone lysis of 3 (76.5%) than in those with lower degrees (33.9% for 1 and 24% for 2) (χ(2) test, p = 0.0004). Sonication cultures were positive in 57% of patients who underwent revision arthroplasty for aseptic loosening. The percentage of positive sonication cultures was significantly higher in patients with severe osteolysis. level I of Prognostic Studies-Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

Revision Arthroplasty for the Aseptic Loosening after Semiconstrained Total Elbow Replacement - Midterm Results -

Purpose: To analyze the clinical results of revision arthroplasty for aseptic loosening after performing semiconstrained total elbow replacement. Materials and Methods: We retrospectively analyzed fifteen patients that had undergone aseptic loosening after semiconstrained total elbow replacement who also had revision arthroplasty. There were 4 men and 11 women, with a mean age of 57 years. The average duration of follow-up was 54 months. The primary causes of arthroplasty were posttraumatic arthrosis (five cases), rheumatoid arthritis (four cases), primary osteoarthritis (four cases), ankylosis (one case) and Charcot joint (one case). For eleven (73%) elbows, the cementing technique was considered marginal or inadequate at the time of primary arthroplasty. An impaction bone graft was used in seven patients at revision, a strut allograft was used in four patients and cement alone was used in four patients. Results: The average preoperative Mayo elbow performance score was 56.6 points; the average postoperative score was 84.5 points. At the latest follow-up, according to the Mayo elbow performance index, six patient elbows showed an excellent result, six patient elbows showed a good result, one patient elbow had a fair result and two patient elbows showed a poor result. Aseptic loosening occurred in three of four elbows that had been revised with cement only. Conclusion: Revision arthroplasty for aseptic loosening after semiconstrained total elbow replacement was useful for the relief of pain, maintenance of stability and the activities of daily living. A poor cementing technique and an inadequate selection of implant may be associated with loosening as a main risk factor. Revision using an impaction graft or strut allograft can be a reliable technique for treating a failed total elbow arthroplasty with massive bone loss.

A comparison of the viscoelastic properties of bone grafts

The expansion in joint arthroplasty surgery in the 1970s has resulted in a large group of patients who require revision arthroplasty for aseptic loosening. Impaction bone grafting to deal with bone stock loss has become an increasingly popular procedure in revision hip surgery. The results of this revision surgery are variable and very much dependent on the grafting techniques adopted at the time of surgery. In vitro testing of impaction bone grafting methods can constitute an important tool to improve long-term clinical results. The increasing clinical demand for human allograft limits its availability for use in in vitro laboratory studies therefore suitable experimental alternatives are required. Human, porcine and ovine cancellous bone grafts were morsellised and prepared for in vitro laboratory testing following a standard operative technique. Each graft type was compressed using a die plunger test. After compression to a predetermined level the graft was left to relax for 120s. A comparison of the compression moduli and of the relaxation characteristics for each graft preparation was performed. In addition, the effects of washing the graft and of cartilage removal from the graft mixture were investigated. This study has demonstrated that there is no statistical difference in the compression modulus or relaxation percentage between human and ovine graft preparations. The effect of removing cartilage and washing the graft mixtures were inconsistent with regard to alterations in the viscoelastic properties of the grafts. On the basis of the experiments performed we recommend the use of ovine bone graft as a suitable substitute for human allograft for in vitro testing of impaction bone grafting methods. The properties of ovine graft were similar for both compression moduli and relaxation properties to human allograft.

Bone-membrane interface in aseptic loosening of total joint arthroplasties

In 19 patients who underwent revision arthroplasty for aseptic loosening of total joint arthroplasty, specimens were taken at the time of operation to include the bone-membrane interface. In 16 (84%) of the specimens, sufficient visualization of the interface was possible to allow histologic interpretation. In 13 of these cases, there was prominent evidence of classic bone remodeling with osteoclastmediated resorption and active new bone formation. These results suggest that the osteolysis in aseptic loosening is mediated through osteoclastic bone resorption and that the bone found in such areas is extremely active. The findings help to explain the efficacy of impacted morselized bone-graft in the treatment of bone lysis in aseptic loosening.

The femoral component in total hip arthroplasty. Six to eight-year follow-up of one hundred consecutive patients after use of a third-generation cementing technique.

One hundred consecutive patients had a primary unilateral total hip arthroplasty with use of a single design of the femoral component (Harris Precoat), inserted with a so-called third-generation cementing technique, between July 1985 and June 1987. There were seventy-four women and twenty-six men. The mean age at the time of the operation was seventy-one years (range, forty-one to ninety-two years) and the mean weight was seventy kilograms (range, forty-eight to 105 kilograms). Eleven of the 100 patients died during the follow-up period, all with the implant in place. Of the eighty-nine surviving patients, one had a revision arthroplasty for aseptic loosening. The mean duration of clinical follow-up for the remaining eighty-eight patients was seven years (range, six to eight years). The mean Harris hip score at the latest follow-up evaluation was 91 points (range, 68 to 97 points). Of the eighty-eight patients, eighty-five (97 percent) had a good or excellent result. Radiographic follow-up was performed for eighty-one patients; none had evidence of loosening of the stem, and five (6 percent) had endosteal cavitation but were asymptomatic. The rate of failure (loosening or revision) of the femoral component in the entire series was 1 per cent (one hip). The low rate of failure and the maintenance of good and excellent clinical and radiographic results during this period of follow-up are consistent with reports from other institutions. This strengthens the argument to retain or widen the existing indications for the insertion of a femoral stem with cement in primary total hip arthroplasty.