Abstract: Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts. Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection.

Abstract: Infection of an orthopedic implant is considered a devastating complication, necessitating its complete removal and thorough debridement of the site. Osseous defects are common in such conditions and need to be addressed before a new implant may be inserted. So far bone grafting has been contraindicated in bacterially contaminated areas and could only be performed as soon as all signs of infection have ceased. Usually long term antibiotic treatment and a multitude of surgical interventions within a period of several months is required until a definitive supply can be achieved. Allograft bone may be impregnated with high loads of antibiotics using special incubation techniques. Based on this technology 48 exchange procedures of infected orthopaedic implants were performed in a single stage, all of them without the use of bone cement. There were 37 infected hips, 8 knees and 3 infected osteosyntheses. Two hips required re-revision because of persisting infection, the remaining 46 patients stayed infect free for a period between 1 and 7 years after surgery. No adverse side effects could be found. Incorporation appeared as after grafting with unimpregnated bone grafts. Antibiotic loaded allograft bone is a powerful tool in septic revision surgery, enabling restoration of bone stock, insertion of a new implant and control of infection in a single operation.

Abstract: This retrospective study reports the 4- to 6-year results of clinical and radiologic follow-up of 60 acetabular revisions using extra-large hemispherical press-fit cups without additional screw fixation. Bone grafts were used in 17 cases. One cup loosened and required re-revision after 12 months. Initial migration was noted in 6 cases, but showed no progression after less than 2 years. In 2 hips that were revised for deep infection, the cups were found incorporated. At final follow-up, 57 hips (95%) were found firmly fixed radiologically. The Harris Hip score improved from a mean of 58.7 points preoperatively to 90.6 points. Provided a high friction coefficient is present, extra-large hemispherical cups offer sufficient stability even in severe cases. Most do not require additional screw fixation.

Abstract: Management of arterial occlusion after total knee arthroplasty is controversial in the literature, in part because of the relatively small number of reported cases. We report a case of perioperative popliteal artery thrombosis after total knee arthroplasty that was treated successfully with percutaneous thrombus aspiration and balloon dilation. Immediate intervention prevented ischemic muscular necrosis, resulting in full recovery of the limb.

Abstract: In order to combine the effects of bone repair and eradication of infection, with both Gram-positive and Gram-negative pathogens, the behaviour of a compound of bone graft and antibiotics was investigated. Samples of human and bovine bone, cancellous and cortical, were processed and incubated with vancomycin and tobramycin, respectively. The compound was placed in 5% human albumin and the surrounding liquid was exchanged completely every 24 h. Concentrations of antibiotics in the fluid were measured over < or = 28 days using high pressure liquid chromatography and a bioassay. All tested combinations eluted mainly in the initial phase with a logarithmic decrease over the testing period. The concentration of antibiotics in the albumin was well above the MIC for common pathogens throughout the investigation in all tested specimens. The highest initial concentrations were measured in the compound of bovine bone together with vancomycin (24395.8 +/- 1138.9 mg/L), decreasing to 9.02 +/- 1.3 mg/L after 11 exchanges. Human and bovine bone did not have significantly different properties. The storage capability of cortical bone was generally lower than that of cancellous bone. Tobramycin concentrations were significantly lower in the initial phase; however, it eluted more steadily and over a longer period, so that from day 6 onwards, its concentration was greater than that of vancomycin. After 28 days, the tobramycin concentration was 18.09 +/- 2.46 mg/L (bovine cancellous bone). In conclusion, bone, if processed adequately, is an excellent carrier for vancomycin and tobramycin. Cortical bone is as suitable as cancellous bone. The pharmacokinetics of human and bovine bone are comparable. Using an antibiotic-graft compound, eradication of pathogens and grafting of bony defects may be accomplished in a one-stage procedure.

Abstract: Metatarsal osteotomy according to Helal is a successful method of treating metatarsalgia. Using this method, 72% of our patients, followed up between 1974 and 1986, (114 patients with a total of 336 osteotomies) were relieved of pain, the result depending on the patients' age. On reviewing the unsuccessful results using pedobarographic measuring, the major part of failures was due to an unequal distribution of weight on the forefoot. Two main types of faulty weight-bearing were stated: 1. Excessive weight-bearing on non-osteotomized adjacent metatarsals (domino-effect). In concern of the overall-result no difference could be found between cases with routine osteotomy II-IV and ones with single or double osteotomy. 2. Excessive weight-bearing on the complete fore-foot as a consequence of missing support by contracted metatarsophalangeal joints. When planning an operation, the length of all metatarsals in relation to each other, as well as the mobility of the toes should therefore be taken into consideration.