Bacterial-infections are mostly due to bacteria in an adhering, biofilm-mode of growth and not due to planktonically growing, suspended-bacteria. Biofilm-bacteria are much more recalcitrant to ...conventional antimicrobials than planktonic-bacteria due to (1) emergence of new properties of biofilm-bacteria that cannot be predicted on the basis of planktonic properties, (2) low penetration and accumulation of antimicrobials in a biofilm, (3) disabling of antimicrobials due to acidic and anaerobic conditions prevailing in a biofilm, and (4) enzymatic modification or inactivation of antimicrobials by biofilm inhabitants. In recent years, new nanotechnology-based antimicrobials have been designed to kill planktonic, antibiotic-resistant bacteria, but additional requirements rather than the mere killing of suspended bacteria must be met to combat biofilm-infections. The requirements and merits of nanotechnology-based antimicrobials for the control of biofilm-infection form the focus of this Tutorial Review.
Background Bone metastases are on the rise due to longer survival of cancer patients. Local tumor control is required for pain relief. Microwave ablation (MWA) is a technique for minimally invasive ...local tumor treatment. Tumor tissue is destroyed by application of local hyperthermia to induce necrosis. Given the most common setting of palliative care, it is generally considered beneficial for patients to start mobilizing directly following treatment. No data on mechanical strength in long bones after MWA have been published so far. Materials and methods In- and ex-vivo experiments on sheep tibias were performed with MWA in various combinations of settings for time and power. During the in-vivo part sheep were sacrificed one or six weeks after ablation. Mechanical strength was examined with a three-point bending test for ablations in the diaphysis and with an indentation test for ablations in the metaphysis. Results MWA does not decrease mechanical strength in the diaphysis. In the metaphysis strength decreased up to 50% six weeks after ablation, which was not seen directly after ablation. Conclusion MWA appears to decrease mechanical strength in long bone metaphysis up to 50% after six weeks, however strength remains sufficient for direct mobilization. The time before normal strength is regained after the remodeling phase is not known.
Biomaterial-associated infections occur on both permanent implants and temporary devices for restoration or support of human functions. Despite increasing use of biomaterials in an aging society, ...comparatively few biomaterials have been designed that effectively reduce the incidence of biomaterial-associated infections. This review provides design guidelines for infection-reducing strategies based on the concept that the fate of biomaterial implants or devices is a competition between host tissue cell integration and bacterial colonization at their surfaces.
Background
For the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking.
Aim and Methods
To address ...this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart.
Results and Conclusion
The approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM).
Background
Reconstruction of periacetabular defects after pelvic tumor resection ranks among the most challenging procedures in orthopaedic oncology, and reconstructive techniques are generally ...associated with dissatisfying mechanical and nonmechanical complication rates. In an attempt to reduce the risk of dislocation, aseptic loosening, and infection, we introduced the LUMiC
®
prosthesis (implantcast, Buxtehude, Germany) in 2008. The LUMiC
®
prosthesis is a modular device, built of a separate stem (hydroxyapatite-coated uncemented or cemented) and acetabular cup. The stem and cup are available in different sizes (the latter of which is also available with silver coating for infection prevention) and are equipped with sawteeth at the junction to allow for rotational adjustment of cup position after implantation of the stem. Whether this implant indeed is durable at short-term followup has not been evaluated.
Questions/purposes
(1) What proportion of patients experience mechanical complications and what are the associated risk factors of periacetabular reconstruction with the LUMiC
®
after pelvic tumor resection? (2) What proportion of patients experience nonmechanical complications and what are the associated risk factors of periacetabular reconstruction with the LUMiC
®
after pelvic tumor resection? (3) What is the cumulative incidence of implant failure at 2 and 5 years and what are the mechanisms of reconstruction failure? (4) What is the functional outcome as assessed by Musculoskeletal Tumor Society (MSTS) score at final followup?
Methods
We performed a retrospective chart review of every patient in whom a LUMiC
®
prosthesis was used to reconstruct a periacetabular defect after internal hemipelvectomy for a pelvic tumor from July 2008 to June 2014 in eight centers of orthopaedic oncology with a minimum followup of 24 months. Forty-seven patients (26 men 55%) with a mean age of 50 years (range, 12–78 years) were included. At review, 32 patients (68%) were alive. The reverse Kaplan-Meier method was used to calculate median followup, which was equal to 3.9 years (95% confidence interval CI, 3.4–4.3). During the period under study, our general indications for using this implant were reconstruction of periacetabular defects after pelvic tumor resections in which the medial ilium adjacent to the sacroiliac joint was preserved; alternative treatments included hip transposition and saddle or custom-made prostheses in some of the contributing centers; these were generally used when the medial ilium was involved in the tumorous process or if the LUMiC
®
was not yet available in the specific country at that time. Conventional chondrosarcoma was the predominant diagnosis (n = 22 47%); five patients (11%) had osseous metastases of a distant carcinoma and three (6%) had multiple myeloma. Uncemented fixation (n = 43 91%) was preferred. Dual-mobility cups (n = 24 51%) were mainly used in case of a higher presumed risk of dislocation in the early period of our study; later, dual-mobility cups became the standard for the majority of the reconstructions. Silver-coated acetabular cups were used in 29 reconstructions (62%); because only the largest cup size was available with silver coating, its use depended on the cup size that was chosen. We used a competing risk model to estimate the cumulative incidence of implant failure.
Results
Six patients (13%) had a single dislocation; four (9%) had recurrent dislocations. The risk of dislocation was lower in reconstructions with a dual-mobility cup (one of 24 4%) than in those without (nine of 23 39%) (hazard ratio, 0.11; 95% CI, 0.01–0.89; p = 0.038). Three patients (6%; one with a preceding structural allograft reconstruction, one with poor initial fixation as a result of an intraoperative fracture, and one with a cemented stem) had loosening and underwent revision. Infections occurred in 13 reconstructions (28%). Median duration of surgery was 6.5 hours (range, 4.0–13.6 hours) for patients with an infection and 5.3 hours (range, 2.8–9.9 hours) for those without (p = 0.060); blood loss was 2.3 L (range, 0.8–8.2 L) for patients with an infection and 1.5 L (range, 0.4–3.8 L) for those without (p = 0.039). The cumulative incidences of implant failure at 2 and 5 years were 2.1% (95% CI, 0–6.3) and 17.3% (95% CI, 0.7–33.9) for mechanical reasons and 6.4% (95% CI, 0–13.4) and 9.2% (95% CI, 0.5–17.9) for infection, respectively. Reasons for reconstruction failure were instability (n = 1 2%), loosening (n = 3 6%), and infection (n = 4 9%). Mean MSTS functional outcome score at followup was 70% (range, 33%–93%).
Conclusions
At short-term followup, the LUMiC
®
prosthesis demonstrated a low frequency of mechanical complications and failure when used to reconstruct the acetabulum in patients who underwent major pelvic tumor resections, and we believe this is a useful reconstruction for periacetabular resections for tumor or failed prior reconstructions. Still, infection and dislocation are relatively common after these complex reconstructions. Dual-mobility articulation in our experience is associated with a lower risk of dislocation. Future, larger studies will need to further control for factors such as dual-mobility articulation and silver coating. We will continue to follow our patients over the longer term to ascertain the role of this implant in this setting.
Level of Evidence
Level IV, therapeutic study.
Background
Grade I or low‐grade chondrosarcoma (LGCS) is a primary bone tumour with low malignant potential. Historically, it was treated by wide resection, since accurate pre‐operative exclusion of ...more aggressive cancers can be challenging and under‐treatment of a more aggressive cancer could negatively influence oncological outcomes. Intralesional surgery for LGCS has been advocated more often in the literature over the past few years. The potential advantages of less aggressive treatment are better functional outcome and lower complication rates although these need to be weighed against the potential for compromising survival outcomes.
Objectives
To assess the benefits and harms of intralesional treatment by curettage compared to wide resection for central low‐grade chondrosarcoma (LGCS) of the long bones.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE and Embase up to April 2018. We extended the search to include trials registries, reference lists of relevant articles and review articles. We also searched 'related articles' of included studies suggested by PubMed.
Selection criteria
In the absence of prospective randomised controlled trials (RCTs), we included retrospective comparative studies and case series that evaluated outcome of treatment of central LGCS of the long bones. The primary outcome was recurrence‐free survival after a minimal follow‐up of 24 months. Secondary outcomes were upgrading of tumour; functional outcome, as assessed by the Musculoskeletal Tumor Society (MSTS) score; and occurrence of complications.
Data collection and analysis
We used standard methodological procedures recognised by Cochrane. We conducted a systematic literature search using several databases and contacted corresponding authors, appraised the evidence using the ROBINS‐I risk of bias tool and GRADE, and performed a meta‐analysis. If data extraction was not possible, we included studies in a narrative summary.
Main results
We included 18 studies, although we were only able to extract participant data from 14 studies that included a total of 511 participants; 419 participants were managed by intralesional treatment and 92 underwent a wide resection. We were not able to extract participant data from four studies, including 270 participants, and so we included them as a narrative summary only. The evidence was at high risk of performance, detection and reporting bias.
Meta‐analysis of data from 238 participants across seven studies demonstrated little or no difference in recurrence‐free survival after intralesional treatment versus wide resection for central LGCS in the long bones (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.92 to 1.04; very low‐certainty evidence). MSTS scores were probably better after intralesional surgery (mean score 93%) versus resection (mean score 78%) with a mean difference of 12.69 (95% CI 2.82 to 22.55; P value < 0.001; 3 studies; 72 participants; low‐certainty evidence). Major complications across six studies (203 participants) were lower in cases treated by intralesional treatment (5/125 cases) compared to those treated by wide resection (18/78 cases), with RR 0.23 (95% CI 0.10 to 0.55; low‐certainty evidence). In four people (0.5% of total participants) a high‐grade (grade 2 or dedifferentiated) tumour was found after a local recurrence. Two participants were treated with second surgery with no evidence of disease at their final follow‐up and two participants (0.26% of total participants) died due to disease. Kaplan‐Meier analysis of data from 115 individual participants across four studies demonstrated 96% recurrence‐free survival after a maximum follow‐up of 300 months after resection versus 94% recurrence‐free survival after a maximum follow‐up of 251 months after intralesional treatment (P value = 0.58; very low‐certainty evidence). Local recurrence or metastases were not reported after 41 months in either treatment group.
Authors' conclusions
Only evidence of low‐ and very low‐certainty was available for this review according to the GRADE system. Included studies were all retrospective in nature and at high risk of selection and attrition bias. Therefore, we could not determine whether wide resection is superior to intralesional treatment in terms of event‐free survival and recurrence rates. However, functional outcome and complication rates are probably better after intralesional surgery compared to wide resection, although this is low‐certainty evidence, considering the large effect size. Nevertheless, recurrence‐free survival was excellent in both groups and a prospective RCT comparing intralesional treatment versus wide resection may be challenging for both practical and ethical reasons. Future research could instead focus on less invasive treatment strategies for these tumours by identifying predictors that help to stratify participants for surgical intervention or close observation.
Obese patients are more likely to develop periprosthetic joint infection (PJI) after primary total joint arthroplasty. This study compared the clinical and microbiological characteristics of ...non-obese, obese and severely obese patients with early PJI, in order to ultimately optimize antibiotic prophylaxis and other prevention measures for this specific patient category.
We retrospectively evaluated patients with early PJI of the hip and knee treated with debridement, antibiotics and implant retention (DAIR) between 2006 and 2016 in three Dutch hospitals. Only patients with primary arthroplasties indicated for osteoarthritis were included. Early PJI was defined as an infection that developed within 90 days after index surgery. Obesity was defined as a BMI ≥30kg/m2 and severe obesity as a BMI ≥35kg/m2.
A total of 237 patients were analyzed, including 64 obese patients (27.0%) and 62 severely obese patients (26.2%). Compared with non-obese patients, obese patients had higher rates of polymicrobial infections (60.3% vs 33.3%, p<0.001) with more often involvement of Enterococcus species (27.0% vs 11.7%, p = 0.003). Moreover, severely obese patients had more Gram-negative infections, especially with Proteus species (12.9% vs 2.3%, p = 0.001). These results were only found in periprosthetic hip infections, comprising Gram-negative PJIs in 34.2% of severely obese patients compared with 24.7% in obese patients and 12.7% in non-obese patients (p = 0.018).
Our results demonstrate that obese patients with early periprosthetic hip infections have higher rates of polymicrobial infections with enterococci and Gram-negative rods, which stresses the importance of improving preventive strategies in this specific patient category, by adjusting antibiotic prophylaxis regimens, improving disinfection strategies and optimizing postoperative wound care.
Orthopedic oncologic surgery requires preservation of a functioning limb at the essence of achieving safe margins. With most bone sarcomas arising from the metaphyseal region, in close proximity to ...joints, joint-salvage surgery can be challenging. Intraoperative guidance techniques like computer-assisted surgery (CAS) and patient-specific instrumentation (PSI) could assist in achieving higher surgical accuracy. This study investigates the surgical accuracy of freehand, CAS- and PSI-assisted joint-preserving tumor resections and tests whether integration of CAS with PSI (CAS + PSI) can further improve accuracy. CT scans of 16 simulated tumors around the knee in four human cadavers were performed and imported into engineering software (MIMICS) for 3D planning of multiplanar joint-preserving resections. The planned resections were transferred to the navigation system and/or used for PSI design. Location accuracy (LA), entry and exit points of all 56 planes, and resection time were measured by postprocedural CT. Both CAS + PSI- and PSI-assisted techniques could reproduce planned resections with a mean LA of less than 2 mm. There was no statistical difference in LA between CAS + PSI and PSI resections (p=0.92), but both CAS + PSI and PSI showed a significantly higher LA compared to CAS (p=0.042 and p=0.034, respectively). PSI-assisted resections were faster compared to CAS + PSI (p<0.001) and CAS (p<0.001). Adding CAS to PSI did improve the exit points, however not significantly. In conclusion, PSI showed the best overall surgical accuracy and is fastest and easy to use. CAS could be used as an intraoperative quality control tool for PSI, and integration of CAS with PSI is possible but did not improve surgical accuracy. Both CAS and PSI seem complementary in improving surgical accuracy and are not mutually exclusive. Image-based techniques like CAS and PSI are superior over freehand resection. Surgeons should choose the technique most suitable based on the patient and tumor specifics.
Lessons Learned
Adjuvant treatment with zoledronic acid did not decrease the recurrence rate of giant cell tumor of bone (GCTB) in this study. The efficacy could not be determined because of the ...small sample size.
GCTB recurrences, even in the denosumab era, are still an issue; therefore, a randomized study exploring the efficacy of zoledronic acid in the adjuvant setting in GCTB is still valid.
Background
Bisphosphonates are assumed to inhibit giant cell tumor of bone (GCTB)‐associated osteoclast activity and have an apoptotic effect on the neoplastic mononuclear cell population. The primary objective of this study was to determine the 2‐year recurrence rate of high‐risk GCTB after adjuvant zoledronic acid versus standard care.
Methods
In this multicenter randomized open‐label phase II trial, patients with high‐risk GCTB were included (December 2008 to October 2013). Recruitment was stopped because of low accrual after the introduction of denosumab. In the intervention group, patients received adjuvant zoledronic acid (4 mg) intravenously at 1, 2, 3, 6, 9, and 12 months after surgery.
Results
Fourteen patients were included (intervention n = 8, controls n = 6). Median follow‐up was long: 93.5 months (range, 48–111). Overall 2‐year recurrence rate was 38% (3/8) in the intervention versus 17% (1/6) in the control group (p = .58). All recurrences were seen within the first 15 months after surgery.
Conclusion
Adjuvant treatment with zoledronic acid did not decrease the recurrence rate of GCTB in this study. The efficacy could not be determined because of the small sample size. Because recurrences, even in the denosumab era, are still an issue, a randomized study exploring the efficacy of zoledronic acid in the adjuvant setting in GCTB is still valid.
经验总结
在本研究中，唑来膦酸辅助治疗未能降低骨巨细胞瘤 (GCTB) 的复发率。由于样本量小，无法确定疗效。
即使是Denosumab 治疗时代，仍存在 GCTB 复发问题，因此，探讨唑来膦酸辅助治疗 GCTB 的有效性随机研究仍然需要。
摘要
背景。双膦酸盐被认为可以抑制骨巨细胞瘤 (GCTB) 相关的破骨细胞活性，诱导肿瘤单核细胞群凋亡。本研究的主要目的是确定唑来膦酸辅助治疗与标准治疗对于高风险 GCTB 2 年复发率的影响。
方法。本项多中心随机开放标签 II 期试验的研究对象为高风险 GCTB 患者(2008 年 12 月至 2013 年 10 月)。Denosumab治疗出现后，由于入组率较低，停止了研究对象的招募。干预组患者于术后 1、2、3、6、9、12 个月后静脉注射唑来膦酸(4mg)辅助治疗。
结果。入组了 14 例患者(干预组 n = 8，对照组 n = 6)。随访时间较长，平均为:93.5 个月(范围:48–111个月)。干预组整体 2 年内复发率为 38% (3/8)，对照组为 17% (1/6) (p = 0.58)。复发病情皆发生于术后 15 个月内。
结论。在本研究中，唑来膦酸辅助治疗未能降低 GCTB 的复发率。由于样本量小，无法确定疗效。即使是使用Denosumab治疗，仍存在 GCTB 复发问题，因此，探讨唑来膦酸辅助治疗 GCTB 的有效性随机研究仍然需要。
Periprosthetic femoral fracture (PPF) after total hip arthroplasty (THA) is a serious complication, as it often is followed by functional deficits and morbidity. There is no consensus regarding the ...optimal stem fixation method and whether additional cup replacement is beneficial. The aim of our study was to perform a direct comparison of reasons and risk of re-revision between cemented and uncemented revision THAs following PPF using registry data.
1,879 patients registered in the Dutch Arthroplasty Registry (LROI) who underwent a first-time revision for PPF between 2007 and 2021 (cemented stem: n = 555; uncemented stem: n = 1,324) were included. Competing risk survival analysis and multivariable Cox proportional hazard analyses were performed.
5- and 10-year crude cumulative incidence of re-revision following revision for PPF was similar between cemented (resp. 13%, 95% CI 10-16 and 18%, CI 13-24) and uncemented (resp. 11%, CI 10-13 and 13%, CI 11-16) revisions. Multivariable Cox regression analysis, adjusting for potential confounders, showed a similar risk of revision for uncemented and cemented revision stems. Finally, we found no difference in risk of re-revision between a total revision (HR 1.2, 0.6-2.1) compared with a stem revision.
We found no difference in the risk of re-revision between cemented and uncemented revision stems after revision for PPF.
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