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There are several therapeutic options for the treatment of periprosthetic joint infections of shoulder arthroplasties. In acute infections, the implant can remain in place with open debridement, septic lavage with antibacterial solutions such as octinedine or polyhexanide solution and exchange of all mobile components. In late infections, the therapeutic options after removal of the infected implant are: permanent spacer, resection arthroplasty, one stage revision and two stage revision with or without a temporary spacer. The functional results are best for one stage revisions, with similar prosthetic survival to two stage revisions. For one stage revisions, the microorganism has to be identified prior to revision surgery, in order to use targeted antibiotics locally in the cement, and systemically., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Extensive tearing of the gluteus muscles (spontaneous or subsequent to hip arthroplasty) is difficult to treat. We are carrying out osseous fixation with securement of the suture anchor by a nonresorbable collagen patch. The objective of this study is to examine the follow-up data of 30 patients and to assess whether the clinical outcomes depended on the extent of the fatty degeneration of the gluteus medius., Methods: Thirty patients (28 female and 2 male) with a mean age of 76.8 ± 4.3 years (68-83 years) were followed for a mean of 46.8 ± 23.1 months (24-101 months)., Results: Pain improved significantly from a preoperative visual analog scale score of 7.0 ± 1.52 (6-10) to 0.83 ± 0.77 (0-3) 24-month postoperative. The gluteus medius muscle force increased from 2.09 ± 0.81 to 3.3 ± 0.78 using the British Medical Research Council Scale. All patients exhibited a severe limp before the operation. Postoperatively, only 5 patients had a severe limp, while 14 exhibited a mild limp and 11 no limp at all. The modified Harris Hip Score increased from a preoperative value of 44.5 ± 4.2 (26-66) to a value of 81.1 ± 7.79 (60-100) 24-month postoperative. The functional results were dependent on the level of fatty degeneration of the muscle., Conclusion: The first results for this surgical technique appear to be very promising for the treatment of extensive tearing of the gluteus musculature that has a degree of fatty degeneration less than 75%., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Periprosthetic joint infection of shoulder arthroplasties is one of the most frequent reasons for pain and revision surgery of shoulder arthroplasties. Propionibacterium acnes is one of the commonest microorganisms causing periprosthetic joint infection in shoulder arthroplasties. It is difficult to detect this slow growing microorganism. This paper gives an overview of the different diagnostic methods. A combination of unspecific and specific tests (detection of microorganism and sensitivity to antibiotics) is helpful in identifying a periprosthetic shoulder infection. Aspiration of the joint can combine different unspecific and specific tests. In patients with punctio sicca and suspected periprosthetic joint infection, we recommend biopsy of periprosthetic tissue., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The treatment of periprosthetic infections of hip arthroplasties typically involves use of either a single- or two-stage (with implantation of a temporary spacer) revision surgery. In patients with severe acetabular bone deficiencies, either already present or after component removal, spacers cannot be safely implanted. In such hips where it is impossible to use spacers and yet a two-stage revision of the prosthetic stem is recommended, we have combined a two-stage revision of the stem with a single revision of the cup. To our knowledge, this approach has not been reported before., Questions/purposes: (1) What proportion of patients treated with single-stage acetabular reconstruction as part of a two-stage revision for an infected THA remain free from infection at 2 or more years? (2) What are the Harris hip scores after the first stage and at 2 years or more after the definitive reimplantation?, Methods: Between June 2009 and June 2014, we treated all patients undergoing surgical treatment for an infected THA using a single-stage acetabular revision as part of a two-stage THA exchange if the acetabular defect classification was Paprosky Types 2B, 2C, 3A, 3B, or pelvic discontinuity and a two-stage procedure was preferred for the femur. The procedure included removal of all components, joint débridement, definitive acetabular reconstruction (with a cage to bridge the defect, and a cemented socket), and a temporary cemented femoral component at the first stage; the second stage consisted of repeat joint and femoral débridement and exchange of the femoral component to a cementless device. During the period noted, 35 patients met those definitions and were treated with this approach. No patients were lost to followup before 2 years; mean followup was 42 months (range, 24-84 months). The clinical evaluation was performed with the Harris hip scores and resolution of infection was assessed by the absence of clinical signs of infection and a C-reactive protein level less than 10 mg/L. All patients were assessed before surgery, between stages, every 3 months during the first year after surgery, every 6 months during the second year postoperative, and at latest followup, and were retrospectively drawn from a longitudinally maintained institutional database., Results: Thirty-four of 35 patients (97.2%; 95% CI, 85.4%-99.5%) appeared free of infection by criteria of Masri et al. and Zimmerli et al. at latest followup. The Harris hip score was 61 ± 13 points after the first operation and 82 ± 16 points 2 years after the second operation., Conclusions: This technique is a promising treatment option for periprosthetic infections of the hip in which substantial acetabular defects exclude implantation of a normal spacer and a two-stage revision of the femoral component is favored., Level of Evidence: Level IV, therapeutic study.

Background: Papers concerning the treatment of periprosthetic infections and acute hematogenous infections often concern inhomogeneous treatment concepts or low numbers of patients; this results in inconsistent rates of treatment success., Methods: Thirty-nine patients with early periprosthetic infections and 28 patients with acute hematogenous infections were treated with a homogeneous concept and followed with a mean period of 41.8 (24-132) months in order to investigate the success rate and influencing factors. All patients were treated with open surgical debridement, a revision of all removable components and irrigation with an antiseptic solution (octinedine). All patients received a systemic vancomycin/rifampicin antibiotic therapy until the microorganism causing the infection could be identified; a specific antibiotic therapy then followed until the end of the sixth week., Results: This unified treatment regimen resulted in an overall success rate of 71.6%, an 82.1% success for early infections and 57.1% for acute hematogenous infections. Variables that influenced the recurrence of an infection were the timespan between revision and first appearance of symptoms (<2 days), the number of previous operations, the American Society of Anesthesiologists classification, and nicotine abuse., Conclusion: It appears that, in cases of early postoperative infection, a reproducibly high rate of success in retaining an implant can be achieved with this specific therapy regime if surgical intervention can be carried out within 2 days of first symptoms., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The value of a transfemoral approach for removal of well-fixed infected hip arthroplasties in 2-stage revision is unclear, especially whether cerclages for closure of the flap in the first step lead to higher reinfection rates and whether reopening of the flap for reimplantation of a hip arthroplasty leads to a lower union rate of the bony flap., Methods: Seventy-six septic 2-stage revisions via a transfemoral approach with cerclages for closure of the flap in the first step and reopening of the flap for reimplantation were followed prospectively for a mean period of 51.2 ± 23.2 (24-118) months., Results: The union rate of the bony flap after reimplantation was 98.7%, and no recurrence of reinfection was recorded in 93.4% of all cases. Subsidence of the stem occurred at a rate of 6.6%, dislocation at a rate of 6.6%, and there was no aseptic loosening of the implants. The Harris Hip Score was 62.2 ± 12.6 points with the spacer and 86.6 ± 15.5 points 2 years after reimplantation. Nine fractures (11.8%) of the flap occurred during the operation because of osteolytic or osteoporotic weakness of the flap itself, but these all healed without further intervention., Conclusion: The transfemoral approach is a safe method for septic revision of well-fixed hip prostheses, and the use of cerclage wires for closing the osteotomy flap in the first stage does not appear to lead to a higher reinfection rate. Similarly, the reopening of the flap does not appear to decrease the union rate of the flap., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Replacement of a loosened acetabular cup attended by massive bone defects involving both columns. Acetabular restoration and proof fixation of a new acetabular cup to restore a pain-free joint function., Indications: Segmental acetabular bone defects involving both columns (Paprosky type 3A, 3B) with loosened acetabular cup or a Girdlestone situation. In case of pelvic discontinuity (Paprosky type 4) combination with reconstructive osteosynthesis plates (for example, Synthes company, Bochum, Germany)., Contraindications: In cases of complete absence of the posterior and especially cranioposterior column combination with structural allograft reconstruction necessary. Relative: acetabular defects, that can be reconstructed by other, smaller implants, for example, press-fit acetabular cups., Surgical Technique: Exposure of the acetabulum by a conventional approach. Removal of the loosened acetabular cup. Cleaning of the acetabulum with a sharp spoon. Rebuilding of the hip center with a reamer. Choice of the size of the antiprotrusion ring using trial implants. Access chiseling for the inferior implant flange into the ischium. If necessary, adaptation of the superior and inferior flange alignment to the individual anatomy by bending. Filling of bone defects with allogenic bone chips. Knocking in of the inferior flange into the ischium. Simultaneous knocking in of both the ring in the acetabulum and the superior flange at the ischium. Screwing in of bolts from the interior of the ring into the iliac bone in the direction of hip forces. Additional positioning of screws due to the superior flange into the iliac bone. Cementing in of a polyethylene cup in the antiprotrusion ring., Postoperative Management: Antithrombotic prophylaxis, physical therapy, gait training under full weight bearing of the limb., Results: 30 acetabular cup revisions with a new Burch-Schneider ring underwent prospective clinical and radiologic examination and were analyzed for an average follow-up of 20.6+/-7.8 months (3-36 months). The Harris Hip Score increased from preoperative 46.6 to postoperative 75.9 points. A loosening of the cage was not recorded.

Objective: Treatment of femoracetabular impingement to prevent or delay the development of secondary osteoarthritis of the hip. Improvement of the mechanical limitation of the range of motion of the hip joint. Pain-free movement of the hip., Indications: Femoroacetabular impingement including a cam impingement, a pincer impingement, as well as mixtures of both types. Osteoarthritis of the hip joint grades 1-3 according to Kellgren induced by a femoroacetabular impingement., Contraindications: Pincer impingement with the necessity of an osteotomy in acetabula malaligned in retroversion. Severe osteoarthritis grade 4 according to Kellgren. Hip infection., Surgical Technique: Supine position of the patient. Longitudinal incision of 5-6 cm in line with the medial border of the anterior superior iliac spine at the level of the greater trochanter, two thirds cranially and one third distally of the tip of greater trochanter. Minimally invasive anterior approach in a modified technique of the Smith-Petersen approach with cutting of the fascia and preservation of the lateral femoral cutaneous nerve running between the two layers of the fascia. Blind preparation between the sartorius muscle and the tensor fasciae latae muscle. Preparation and T-shaped opening of the joint capsule in the direction of the capsule fibers and the anterior iliofemoral ligament. Removal of additional bone mostly in the ventral area of the femoral neck with angled and straight chisels. Using different positions of the leg helps to reach the more medial and lateral areas of the femoral neck. A trimming of the acetabulum with or without refixation of the labrum in the anterior and anterocranial acetabular rim is also possible. Documentation using fluoroscopy. Wound closure., Postoperative Management: Prophylaxis of deep venous thrombosis. Early functional mobilization with unlimited range of motion of the hip joint. The amount of weight bearing is influenced by the amount of bone resection during trimming. In most cases, full weight bearing is possible. In cases of extensive bone resection (more than one fourth of the femoral neck diameter), gradual increase of weight bearing over 6 weeks., Results: After a follow-up of 15.5 +/- 6.8 months, 65 patients (20 female, 45 male; 70 hip joints) aged 40.2 +/- 11.3 years showed an improvement of the Oxford Hip Score from 34.3 +/- 9.8 points preoperatively to 16.3 +/- 11.0 points and of the WOMAC (Western Ontario and McMaster Universities) Score from 60.8 +/- 23.1 points to 84.0 +/- 15.1 points at the latest follow-up examination. The impingement test was negative in all cases. In twelve cases, a temporary hypesthesia of the cranial innervation area of the lateral femoral cutaneous nerve was reported.

Objective: The aim of the present study was to perform a comparative evaluation of septic and aseptic interface membranes, assessing histological features, inflammatory infiltrate, and expression of inflammatory cytokines., Methods: Septic and aseptic interface membranes from 102 patients were examined by histology, histochemistry, and immunohistochemistry (tissue arrays). The cell subpopulations were characterized by quantification of CD3, CD4, CD8, CD20, and CD163 positive cells. Additionally, a semiquantitative evaluation of inflammatory cytokines (TNFalpha, TGF-beta1, IL-1, IL-6, CRP, MMP-1, MMP-6) was performed to complete the analysis of inflammatory infiltrates., Results: The histological analysis revealed three different types of aseptic interface membranes: wear particle, degenerative, and mixed type. The expression of inflammatory molecules did not differ between septic and wear particle interface membranes. Significantly lower expression of cytokines, MMPs and CRP was observed, however, in degenerative interface membranes compared to other types. No expression of TNFalpha was observed in the degenerative interface membranes. Over 88% of patients with degenerative interface membranes had had a clinical record of osteoarthritis., Conclusion: Aseptic interface membranes were represented by wear particle, degenerative and mixed type. The expression of inflammatory factors in wear particle type is similar to this in septic membranes and can contribute to the bone destruction and prosthesis loosening. These factors seem not to play a major role in the degenerative membranes.