Andrea Pace

Background: Determining infection eradication before reimplantation remains challenging during two-stage revision for chronic periprosthetic joint infections (PJI). This exploratory study investigated the association between serial postoperative C-reactive protein (CRP) trajectories and treatment outcome following prosthesis explantation during two-stage revision for chronic periprosthetic joint infection (PJI). Methods: We retrospectively reviewed patients undergoing two-stage revision for chronic hip or knee PJI between January 2020 and August 2024. Patients with weekly CRP measurements and at least 12 months of follow-up were included. Treatment failure was defined according to modified Delphi criteria. Weekly CRP concentrations and percentage changes from postoperative Week 1 (ΔCRP) were compared between groups. ROC analysis assessed CRP discrimination weekly. Results: Ninety-one patients were included; 50 (54.9%) achieved infection eradication and 41 (45.1%) experienced treatment failure. CRP increased during the first post-operative week in both groups. Week 1 CRP concentrations were not significantly different between groups (5.24 vs. 6.79 mg/dL, p = 0.108). From Week 2 onwards, postoperative CRP trajectories and relative reductions from Week 1 differed between patients with treatment success and those experiencing treatment failure. From Week 2 onward, CRP remained significantly higher in patients with treatment failure (Week 2: 3.91 vs. 2.27 mg/dL, p = 0.0017; Week 4: 3.28 vs. 0.94 mg/dL, p < 0.0001; Week 6: 2.16 vs. 0.70 mg/dL, p = 0.0007). Relative CRP reduction was significantly higher in the success group from Week 2 onward. Discriminatory performance improved over time, with AUCs of 0.699–0.782 at Weeks 2–6. Conclusions: In this exploratory cohort, postoperative CRP trajectories differed according to treatment outcome. A slower decline in CRP was associated with treatment failure, but these findings do not establish an independent prognostic effect. CRP should not determine reimplantation timing in isolation, but an unfavourable trajectory should prompt reassessment and consideration of repeat debridement and spacer exchange. Larger prospective multicentre studies are needed to confirm these associations and determine their clinical utility.

Background Given the increased life expectancy, an increasing number of proximal femur fractures (PFFs) will occur in centenarian patients. In these patients, PFF has a serious impact on quality of life with high morbidity and mortality and an increase in total cost of care. Therefore, it is important to understand the surgical outcome for this group of patients defining preoperative risk factors. Material and method From January 1, 2010, to December 31, 2020, 33 centenarian patients with PFF were treated with locked nail or hemiarthroplasty. Mortality risk factors were assessed. Several survival-related factors were evaluated using the log-rank test and univariate Cox regression statistical analysis for categorical and quantitative variables, respectively. Significative variables at the univariate analysis were included in the Cox multivariate model, using Backward Elimination technique. A P value of < 0.05 was considered statistically significant for all tests. Software STATA 17.0 was used for statistical analysis. Results Centenarians with femoral neck and pertrochanteric fracture were treated with hemiarthroplasty and locked nail, respectively. At the time of admission, only 21% had normal hemoglobin value. Postoperatively, a moderate anemia was observed in 45% of patients and a severe dementia was observed in 18%. In 85% of patients, Charlson Index was less than 3. At the time of admission, 30% of them were considered independent in walking and activity of daily living (ADL), but at discharge ambulation was worsened and none of them were independent in ADL at one month. Postoperative delirium was observed in 30% of patients preventing a complete rehabilitation program. One month after discharge 27% of patients were readmitted in hospital for complications. Mortality was 16%, 59%, and 66% at 1–6–12 months, respectively. At a multivariate evaluation, male, severe anemia and Functional Ambulation Categories (FAC) score < 3 at admission were the only variables statistically related to high risk of mortality. Conclusion The anemia value was found to be related to mortality, and a quick restoration of these values is necessary. Geriatric and functional status scores, especially FAC score, are related to survival, providing an accurate prognosis. In our study, a high percentage of patients are unable to return to their pre-fracture level of independence. This suggests that the prognosis for centenarian patients with PFF may be as poor as previously thought.

Periprosthetic infection (PJI) after TAR is a serious complication, often requiring further surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. This systematic review aims to summarize the current evidence on the management of TAR PJI and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Seventy-one studies met the inclusion criteria, reporting on cases of TAR PJI. A total of 298 PJIs were retrieved. The mean incidence of PJI was 3.8% (range 0.2–26.1%). Furthermore, 53 (17.8%) were acute PJIs, whereas most of them (156, 52.3%) were late PJIs. Most of the studies were heterogeneous regarding the treatment protocols used, with a two-stage approach performed in most of the cases (107, 35.9%). While the prevalence of ankle PJI remains low, it is potentially one of the most devastating complications of TAR. This review highlights the lack of strong literature regarding TAR infections, thus highlighting a need for multicentric studies with homogeneous data regarding the treatment of ankle PJI to better understand outcomes.

Hip arthroplasty failures (either septic or aseptic) often require multiple revisions, thus leading to severe bone defects. The most common reconstruction methods do not allow the management of severe defects. For this reason, in recent years, techniques borrowed from surgical oncology have been applied in the field of revision surgery to deal with both acetabular and femoral bone losses. In this article, two cases of severe bone deficiency following multiple hip arthroplasty revisions that were treated with a custom-made hip prosthesis combined with a proximal femur megaprosthesis are presented. Both implants were silver coated. A review of the literature was conducted to analyze similar cases treated with either a custom-made prosthesis or a proximal femur megaprosthesis. At the 2-year follow-up, all prostheses were in site without clinical or radiographic signs of implant loosening. No postoperative complications occurred. At the last follow-up, both patients resumed their daily life activities with an MSTS score of 23 and 21, respectively. The combined approach of a proximal femur megaprosthesis with a custom-made partial pelvic replacement is a solution that allows severe bone deficiency cases to be tackled with good functional results. Additionally, silver coating may help prevent recurrence of infection.

Background: Femoral neck fractures are an epidemiologically significant issue with major effects on patients and health care systems, as they account for a large percentage of bone injuries in the elderly. Hip hemiarthroplasty is a common surgical procedure in the treatment of displaced femoral neck fractures. Several surgical approaches may be used to access the hip joint in case of femoral neck fractures, each with its own benefits and potential drawbacks, but none of them has consistently been found to be superior to the others. This article aims to systematically review and compare the different approaches in terms of the complication rate at the last follow-up. Methods: an in-depth search on PubMed/Scopus/Web of Science databases and a cross-referencing search was carried out concerning the articles comparing different approaches in hemiarthroplasty and reporting detailed data. Results: A total of 97,576 hips were included: 1030 treated with a direct anterior approach, 4131 with an anterolateral approach, 59,110 with a direct lateral approach, and 33,007 with a posterolateral approach. Comparing the different approaches, significant differences were found in both the overall complication rate and the rate of revision surgery performed (p < 0.05). In particular, the posterolateral approach showed a significantly higher complication rate than the lateral approach (8.4% vs. 3.2%, p < 0.001). Furthermore, the dislocation rate in the posterolateral group was significantly higher than in the other three groups considered (p < 0.026). However, the posterolateral group showed less blood loss than the anterolateral group (p < 0.001), a lower intraoperative fractures rate than the direct anterior group (p < 0.035), and shorter mean operative time than the direct lateral group (p < 0.018). Conclusions: The posterolateral approach showed a higher complication rate than direct lateral approach and a higher prosthetic dislocation rate than the other three types of surgical approaches. On the other hand, patients treated with posterolateral approach showed better outcomes in other parameters considered, such as mean operative time, mean blood loss and intraoperative fractures rate. The knowledge of the limitations of each approach and the most common associated complications can lead to choosing a surgical technique based on the patient’s individual risk.