Publications by authors named "Martín A Buttaro"

36 Publications

Patients with no recurrence of infection five years after two-stage revision hip arthroplasty may be classified as periprosthetic infection 'in remission'.

Bone Joint J 2021 Jan;103-B(1):79-86

'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Aims: We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA).

Methods: We retrospectively reviewed 96 cases which met the Musculoskeletal Infection Society criteria for PJI. The mean follow-up was 90 months (SD 32). Septic failure was assessed using a Delphi-based consensus definition. Any further surgery undertaken for aseptic mechanical causes was considered as aseptic failure. The cumulative incidence with competing risk analysis was used to predict the risk of septic failure. A regression model was used to evaluate factors associated with septic failure. The cumulative incidence of aseptic failure was also analyzed.

Results: There were 23 septic failures at final follow-up, with a cumulative incidence of 14% (95% confidence interval (CI) 8% to 22%) at one year, 18% (95% CI 11% to 27%) at two years, 22% (95% CI 14% to 31%) at five years, and 23% (95% CI 15% to 33%) at ten years. Having at least one positive culture (hazard ratio (HR) 2.38 (interquartile range (IQR) 1.19 to 4.74); p = 0.013), or a positive intraoperative frozen section (HR 2.55 (IQR 1.06 to 6.15); p = 0.037) was significantly associated with septic failure after reimplantation. With dislocation being the most common cause of aseptic revision (5.2%), the cumulative incidence of aseptic failure was 1% (95% CI 0% to 5%) at one year, 6% (95% CI 1% to 8%) at five years, and 8% (95%CI 3% to 17%) at ten years.

Conclusion: If there is no recurrent infection in the five years following reimplantation, the chances of further infection thereafter are remote. While the results of a frozen section may be a reliable guide to the timing of reimplantation, intraoperative culture has, currently, only prognostic value. Surgeons should be aware that instability remains a potential indication for further revision surgery. Cite this article: 2021;103-B(1):79-86.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-0955.R1DOI Listing
January 2021

Hip preservation surgery and the acetabular fossa.

Bone Joint Res 2020 Dec;9(12):857-869

Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Canada.

As our understanding of hip function and disease improves, it is evident that the acetabular fossa has received little attention, despite it comprising over half of the acetabulum's surface area and showing the first signs of degeneration. The fossa's function is expected to be more than augmenting static stability with the ligamentum teres and being a templating landmark in arthroplasty. Indeed, the fossa, which is almost mature at 16 weeks of intrauterine development, plays a key role in hip development, enabling its nutrition through vascularization and synovial fluid, as well as the influx of chondrogenic stem/progenitor cells that build articular cartilage. The pulvinar, a fibrofatty tissue in the fossa, has the same developmental origin as the synovium and articular cartilage and is a biologically active area. Its unique anatomy allows for homogeneous distribution of the axial loads into the joint. It is composed of intra-articular adipose tissue (IAAT), which has adipocytes, fibroblasts, leucocytes, and abundant mast cells, which participate in the inflammatory cascade after an insult to the joint. Hence, the fossa and pulvinar should be considered in decision-making and surgical outcomes in hip preservation surgery, not only for their size, shape, and extent, but also for their biological capacity as a source of cytokines, immune cells, and chondrogenic stem cells. Cite this article: 2020;9(12):857-869.
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http://dx.doi.org/10.1302/2046-3758.912.BJR-2020-0254.R1DOI Listing
December 2020

International Organism Profile of Periprosthetic Total Hip and Knee Infections.

J Arthroplasty 2021 01 16;36(1):274-278. Epub 2020 Jul 16.

Orthopaedic Department, Helios Klinikum, Berlin, Germany.

Background: There is scarce literature describing pathogens responsible for periprosthetic joint infections (PJIs) around the world. Therefore, we sought to describe periprosthetic joint infection causative organisms, rates of resistant organisms, and polymicrobial infections at 7 large institutions located in North/South America and Europe.

Methods: We performed a retrospective study of 654 periprosthetic hip (n = 361) and knee (n = 293) infections (January 2006 to October 2019) identified at Cleveland Clinic Ohio/Florida in the United States (US) (n = 159), Hospital Italiano de Buenos Aires in Argentina (n = 99), Hospital Asociación Española in Uruguay (n = 130), Guy's and St Thomas' Hospital in the United Kingdom (UK) (n = 103), HELIOS Klinikum in Germany (n = 59), and Vreden Institute for Orthopedics in St. Petersburg, Russia (n = 104). Analyses were performed for the entire cohort, knees, and hips. Alpha was set at 0.05.

Results: Overall, the most frequent organisms identified were Staphylococcus aureus (24.8%) and Staphylococcus epidermidis (21.7%). The incidence of organisms resistant to at least one antibiotic was 58% and there was a significant difference between hips (62.3%) and knees (52.6%) (P = .014). Rates of resistant organisms among countries were 37.7% (US), 66.7% (Argentina), 71.5% (Uruguay), 40.8% (UK), 62.7% (Germany), and 77.9% (Russia) (P < .001). The overall incidence of polymicrobial infections was 9.3% and the rates across nations were 9.4% in the US, 11.1% in Argentina, 4.6% in Uruguay, 4.9% in UK, 11.9% in Germany, and 16.3% in Russia (P = .026).

Conclusion: In the evaluated institutions, S aureus and S epidermidis accounted for almost 50% of all infections. The US and the UK had the lowest incidence of resistant organisms while Germany and Russia had the highest. The UK and Uruguay had the lowest rates of polymicrobial infections.
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http://dx.doi.org/10.1016/j.arth.2020.07.020DOI Listing
January 2021

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations.

Knee Surg Sports Traumatol Arthrosc 2020 Sep 17;28(9):2747-2755. Epub 2020 Aug 17.

CortoClinics, Schijndel, The Netherlands.

Purpose: To plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections.

Method: A systematic review was conducted using the terms "COVID-19" or "SARS-Cov-2" and "second wave". No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations.

Results: Overall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family's lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves.

Conclusions: The recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.
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http://dx.doi.org/10.1007/s00167-020-06213-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429418PMC
September 2020

Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology.

Int Orthop 2020 10 8;44(10):1887-1895. Epub 2020 Aug 8.

'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina.

Purpose: To analyse the impact of prolonged mandatory lockdown due to COVID-19 on hip fracture epidemiology.

Methods: Retrospective case-control study of 160 hip fractures operated upon between December 2019 and May 2020. Based on the date of declaration of national lockdown, the cohort was separated into two groups: 'pre-COVID time' (PCT), including 86 patients, and 'COVID time' (CT), consisting of 74 patients. All CT patients tested negative for SARS-CoV-2. Patients were stratified based on demographic characteristics. Outcome measures were 30-day complications, readmissions and mortality. A logistic regression model was run to evaluate factors associated with mortality.

Results: Age, female/male ratio, body mass index and American Society of Anaesthesia score were similar between both groups (p > 0.05). CT patients had a higher percentage of Charlson ≥ 5 and Rockwood Frailty Index ≥ 5 scores (p < 0.05) as well as lower UCLA and Instrumental Activities of Daily Living scores (p < 0.05). This translated into a higher hemiarthroplasty/total hip arthroplasty ratio during CT (p = 0.04). Thromboembolic disease was higher during CT (p = 0.02). Readmissions (all negative for SARS-CoV-2) were similar between both groups (p = 0.34). Eight (10.8%) casualties were detected in the CT group, whereas no deaths were seen in the control group. Logistic regression showed that frailer (p = 0.006, OR 10.46, 95%CI 8.95-16.1), less active (p = 0.018, OR 2.45, 95%CI 1.45-2.72) and those with a thromboembolic event (p = 0.005, OR 30, 95%CI 11-42) had a higher risk of mortality.

Conclusion: Despite testing negative for SARS-CoV-2, CT patients were less active and frailer than PCT patients, depicting an epidemiological shift that was associated with higher mortality rate.
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http://dx.doi.org/10.1007/s00264-020-04769-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414899PMC
October 2020

Hypovitaminosis D in lower extremity Joint Arthroplasty: A systematic review and meta-analysis.

J Orthop 2020 Sep-Oct;21:109-116. Epub 2020 Mar 25.

Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA.

The purpose of the current systematic review was to identify the prevalence of hypovitaminosis-D in LE-TJA patients; and outline the association between pre-operative hypovitaminosis and post-operative outcomes. A search of PubMed-Medline and the Cochrane-Library databases was performed for literature published before November 27th, 2019 The eighteen studies analyzed had a pooled prevalence for vitamin D insufficiency (20 - <30 ng/mL) and deficiency (<20 ng/mL) of 53.4% and 39.4%, respectively. Hypovitaminosis-D was associated with higher complication rates ( = 0.043), and a greater prevalence among septic versus aseptic revisions ( = 0.016). Therefore, pre-operative screening for hypovitaminosis-D can be beneficial in patients undergoing LE-TJA.

Level Of Evidence: Systematic Review (Level III).
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http://dx.doi.org/10.1016/j.jor.2020.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7114851PMC
March 2020

4- to 8-year complication analysis of 2 'partial collum' femoral stems in primary THA.

Hip Int 2021 Jan 26;31(1):75-82. Epub 2019 Sep 26.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Objectives: Compare the clinical and radiological outcome of CFP stem with the MiniHip design in a prospective series, with special interest in intraoperative periprosthetic fracture (IPPF).

Methods: We prospectively followed 101 cases treated with the MiniHip stem (Group 1) and 89 with the CFP stem (Group 2) operated between 2010 and 2014. No significant demographic differences were observed between both groups. Median follow-up was 72 months. Average stem length was 41% shorter in the MiniHip group (  0.001). Radiological parameters were measured and a logistcic regression model was created to evaluate factors associated with IPPF.

Results: Mean mHHS improved from 54 to 95 in the MiniHip group (  0.001) and from 64 to 98 in the CFP group (  0.001). No significant differences were observed in terms of loosening, infection or instability. We observed 7 IPPFs (3.68%), 3 in group 1 and 4 in group 2. After adjusting for confounders, CFP was not associated with a greater risk of IPPF (OR 3.23; 95% CI, 0.250-42.034,   0.368), however, a more complex fracture pattern was observed with this stem design. Prior acetabular fractures were associated with IPPF (OR 66.85; 95% CI, 1.142-3911,   0.043). Compared to Dorr A femurs, type Dorr B appeared protective against IPPF (OR 0.039; 95% CI, 0.001-1.109,   0.058). Valgus alignment tended to increase the risk of IPPF (OR 20.59; 95% CI 0.870-487.221,   0.061).

Conclusions: MiniHip showed similar radiological outcomes to CFP at short- to mid-term follow-up without increasing IPPFs with a shorter stem length. Given that CFP produced a more complex IPPF pattern, surgeons should be cautious with alignment of this particular design, especially in Dorr A femur.
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http://dx.doi.org/10.1177/1120700019879360DOI Listing
January 2021

Are there any risk factors for developing complications with the use of retrievable vena cava filters in orthopaedic surgery?

Rev Fac Cien Med Univ Nac Cordoba 2018 06 11;75(2):119-127. Epub 2018 Jun 11.

.

Background: In high-risk patients, common prophylaxis may be insufficient to prevent thromboembolic events after orthopaedic procedures. In this scenario, a retrievable vena cava filter (VCF) could be considered as an alternative, although it's use remains controversial. Therefore, we asked: (1) what is the overall mechanical complication rate associated with the use of retrievable VCFs in orthopaedic surgery?, (2) what is the association with thromboembolic disease (TED) recurrence, post-thrombotic syndrome and/or major bleeding according to different surgical characteristics?, (3) What is the overall mortality rate attributed to VCF use?

Methods: We retrospectively analyzed a cohort of 68 patients who underwent orthopaedic surgery with a previous diagnosis of TED, in whom a retrievable VCF was placed. Permanent filters were excluded. We studied the filter's mechanical complications and considered as possible outcomes death and 3 hematologic complications: TED recurrence, post-thrombotic syndrome and major bleeding. To estimate association with risk factors, we subclassified surgeries into 5 groups: 1, arthroplasty/non-arthroplasty; 2, primary/revision; 3, elective/urgent; 4, oncologic/non-oncologic; 5, preoperative/postoperative filter.

Results: Mechanical complications were 16% and required a filter revision. Sixty-four percent of the revised VCFs developed a mechanical failure and could not be retrieved. Overall prevalence of TED recurrence, post-thrombotic syndrome and hemorrhage was 33%, 15% and 4.5%, respectively. Spinal surgeries were a risk factor for developing TED recurrences.  Only 4% of patients died of a TED recurrence.

Conclusions: Orthopaedic procedures had a high risk of mechanical and hematologic complications after using a retrievable VCF. However, mortality was low due to these complications.
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http://dx.doi.org/10.31053/1853.0605.v75.n2.17746DOI Listing
June 2018

State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty.

EFORT Open Rev 2018 Jul 17;3(7):434-441. Epub 2018 Jul 17.

Hip Surgery Unit, Italian Hospital of Buenos Aires, Argentina.

Acute peri-prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a potentially devastating and undesired complication, with a prevalence of 0.3% to 2.9%. Its suspicion begins with a meticulous physical examination and anamnesis. Diagnosis should be made on the basis of the Musculoskeletal Infection Society criteria. Serum and synovial biomarkers are very useful tools when major criteria are absent.Although sometimes not possible due to medical conditions, surgery is usually the first line of treatment. Although its outcome is highly correlated with the isolated microorganism, irrigation and debridement with implant retention (DAIR) is the gold standard for treatment. Ideally, the prior approach should be proximally and distally extended to augment the field of view and remove all of the prosthetic modular components, that is, femoral head and acetabular insert.Given DAIR's unclear control of infection, with successful outcomes in the range of 30% to 95%, one- or two-stage revision protocols may play a role in certain cases of acute infections; nonetheless, further prospective, randomized studies are necessary to compare long-term outcomes between DAIR and revision surgeries.Following surgical treatment, length of antibiotherapy is in the range of six weeks to six months, without any difference in outcomes between short and long protocols. Treatment should be adjusted to the isolated bacteria and controlled further with post-operative serum biomarker levels. Cite this article: 2018;3:434-441. DOI: 10.1302/2058-5241.3.170032.
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http://dx.doi.org/10.1302/2058-5241.3.170032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129958PMC
July 2018

Transfusion rate using intravenous tranexamic acid in hip revision surgery.

Hip Int 2018 Mar;28(2):194-199

Hip Surgery Centre "Sir John Charnley", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: Hip revision surgery is associated with a high probability of the necessity for a blood transfusion. Different studies support the use of tranexamic acid (TXA) to decrease the rate of transfusions in primary hip surgery. Nevertheless, the use of this drug in hip revision surgery has not yet been widely accepted. The aim of our study was to establish the rate of blood transfusion with and without TXA in hip revision surgery.

Methods: We retrospectively studied 125 hip revision surgery patients operated on between 2011 and 2014. We divided our series into 2 groups: the TXA group with 61 patients (in which a 1000 mg dose of TXA was used before the skin incision and a second identical dose after skin closure) and a control group with 64 patients. We analysed the red blood cell (RBC) transfusion rates and their odds risk as well as the presence of collateral complications.

Results: Average RBC transfusion was 2.7 units/patient (range 0-6) in the control group compared to 1.6 units/patient (range 0-6) in the TXA group. A 90.11% (odds ratio [OR] 0.098; confidence interval [CI] 0.02-0.04; p<0.0029) odds risk reduction for transfusion of at least 1 unit of erythrocyte blood cell was observed in the TXA group. Complications associated with the TXA were similar in both groups.

Interpretation: The benefits of TXA have been shown in elective hip replacement. In this study, TXA proved to be safe and efficacious in reducing the need for transfusions following revision total hip arthroplasty.
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http://dx.doi.org/10.1177/1120700018768655DOI Listing
March 2018

Re-admissions treble the risk of late mortality after primary total hip arthroplasty.

Int Orthop 2018 09 10;42(9):2015-2023. Epub 2018 Mar 10.

Hip Surgery Unit, 'Carlos E. Ottolenghi' Institute of Orthopaedics, Italian Hospital of Buenos Aires, 4247 Potosi St, ACK1199, Buenos Aires, Argentina.

Background: Following a total hip arthroplasty (THA), early hospital re-admission rates of 3-11% are considered as 'acceptable' in terms of medical care cost policies. Surprisingly, the impact of re-admissions on mortality has not been priorly portrayed. Therefore, we sought to determine the mortality rate after 90-day re-admissions following a THA in a series of patients from a captive medical care program.

Patients And Methods: We prospectively analysed 90-day readmissions of 815 unilateral, elective THA patients operated upon between 2010 and 2014 whose medical care was the one offered by our institution. We stratified our sample into readmitted and non-readmitted cohorts. Through a Cox proportional hazards model, we compared demographic characteristics, clinical comorbidities, surgical outcomes and laboratory values between both groups in order to determine association with early and late mortality.

Results: We found 37 (4.53%) re-admissions at a median time of 40.44 days (IQR 17.46-60.69). Factors associated with re-admission were hospital stay (p = 0.00); surgical time (p = 0.01); chronic renal insufficiency (p = 0.03); ASA class 4 (p = 0.00); morbid obesity (p = 0.006); diabetes (p = 0.04) and a high Charlson index (p = 0.00). Overall mortality rate of the series was 3.31% (27/815). Median time to mortality was 455.5 days (IQR 297.58-1170.65). One-third (11/37) of the re-admitted patients died, being sepsis non-related to the THA the most common cause of death. After adjusting for confounders, 90-day re-admissions remained associated with mortality with an adjusted HR of 3.14 (CI95% 1.05-9.36, p = 0.04).

Conclusions: Unplanned re-admissions were an independent risk factor for future mortality, increasing three times the risk of mortality.
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http://dx.doi.org/10.1007/s00264-018-3876-0DOI Listing
September 2018

Is a short stem suitable for patients with hip dysplasia? A report on technical problems encountered during femoral reconstruction.

Hip Int 2018 May 14;28(3):315-323. Epub 2017 Oct 14.

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: A wide variety of stems have been used for the treatment of osteoarthritis secondary to advanced hip dysplasia. Since evidence for using short stems in dysplastic hips is limited, we planned to analyse the technical problems encountered when reconstructing the proximal femur of patients with osteoarthritis secondary to congenital dysplasia of the hip treated with total hip arthroplasty (THA) using a type 2B short stem.

Methods: We prospectively analysed 17 patients (22 hips) treated with primary THA performed with a single-branded short uncemented stem with metaphyseal fixation (MiniHip™; Corin). We excluded cases in which other type of stems were used, or in which retrospective data was only available. Mean follow-up was 41.22 months (minimum 24). We analysed clinical outcome using the modified Harris Hip Score (mHHS) and pain using the visual analogue scale (VAS). Radiographs were examined in order to determine causes of complications and revision surgery.

Results: All patients showed statistically significant improvement when preoperative and postoperative values for mHHS (54.19 vs. 94.57; p = 0.0001) and for pain VAS (8.71 vs. 0.71; p = 0.0003) were compared. No cases of thigh pain, instability or infection were found. 1 case of acetabular cup loosening and 1 case of periprosthetic fracture were diagnosed at 8 months and 45 days, respectively. Overall survival was 84.7% at 5 years (CI 95%, 64.4-105.3) with revision for any reason as an end point. When stem performance was separately evaluated, it showed a survival rate of 100% at 5 years with revision for aseptic loosening as an end point.

Conclusions: THA with a type 2B short stem for the treatment of dysplastic osteoarthritis showed very few technical intraoperative problems, being a useful alternative for femoral reconstruction.
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http://dx.doi.org/10.5301/hipint.5000562DOI Listing
May 2018

THA conversion rate comparing decompression alone, with autologous bone graft or stem cells in osteonecrosis.

Hip Int 2018 03 10;28(2):189-193. Epub 2017 Sep 10.

"Sir John Charnley" Hip centre, "Carlos E. Ottolenghi" Orthopaedic and Traumatology Institute, Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: Core decompression (CD) with or without the addition of autologous bone graft (CDBG) is currently the most widely accepted treatment for hip osteonecrosis in stages of pre-collapse. The use of bone marrow mesenchymal stem cells (CDSC) is emerging as a promising biological alternative. We sought to determine the total hip arthroplasty (THA) conversion rate for patients treated with CD, CDBG or CDSC.

Material And Methods: Between 1996 and 2012, 97 cases were evaluated in 72 patients: 47 CD cases, 34 CDGB cases and 16 CDSC cases. The mean age was 39 (20-63) years, 25 bilateral, 19 female and 53 male, 14 Ficat 1 and 83 Ficat 2. Bilateral cases with asymmetric stage and equal treatment were excluded.

Results: Conversion rate to THA was 44% for the CD group (21/47) at an average of 77 (24-324) months; 50% for the CDBG group (17/34) at an average of 34 (24-240) months and 50% for the CDSC group (8/16) at an average of 48 (24-72) months (p = 0.619). Log Rank test for survivorship analysis was not significant (p = 0.2011). Immunodeficiency or corticosteroid treatment history was associated with 16/47 of the CD group, 7/34 in the CDBG group and 1/16 in the CDSC group. Trauma was associated with 2/47 of the CD group, 5/34 of the CDBG group and none of the CDSC group. Hazard ratio considering risk factors was not significant (p = 0.252).

Conclusions: In these series of cases including patients with pre-collapse osteonecrosis, we observed non-significant results regarding rate of conversion to THA with CD, CDBG or CDSC at an average of 5.5 years.
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http://dx.doi.org/10.5301/hipint.5000552DOI Listing
March 2018

Transfusion rate using intravenous tranexamic acid in hip revision surgery.

Hip Int 2017 Oct 12. Epub 2017 Oct 12.

Hip Surgery Centre "Sir John Charnley", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Introduction: Hip revision surgery is associated with a high probability of the necessity for a blood transfusion. Different studies support the use of tranexamic acid (TXA) to decrease the rate of transfusions in primary hip surgery. Nevertheless, the use of this drug in hip revision surgery has not yet been widely accepted. The aim of our study was to establish the rate of blood transfusion with and without TXA in hip revision surgery.

Methods: We retrospectively studied 125 hip revision surgery patients operated on between 2011 and 2014. We divided our series into 2 groups: the TXA group with 61 patients (in which a 1000 mg dose of TXA was used before the skin incision and a second identical dose after skin closure) and a control group with 64 patients. We analysed the red blood cell (RBC) transfusion rates and their odds risk as well as the presence of collateral complications.

Results: Average RBC transfusion was 2.7 units/patient (range 0-6) in the control group compared to 1.6 units/patient (range 0-6) in the TXA group. A 90.11% (odds ratio [OR] 0.098; confidence interval [CI] 0.02-0.04; p<0.0029) odds risk reduction for transfusion of at least 1 unit of erythrocyte blood cell was observed in the TXA group. Complications associated with the TXA were similar in both groups.

Interpretation: The benefits of TXA have been shown in elective hip replacement. In this study, TXA proved to be safe and efficacious in reducing the need for transfusions following revision total hip arthroplasty.
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http://dx.doi.org/10.5301/hipint.5000555DOI Listing
October 2017

Outcomes of nondisplaced intracapsular femoral neck fractures with internal screw fixation in elderly patients: a systematic review.

Hip Int 2018 01;28(1):18-28

3 Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires - Argentina.

Introduction: Although the preferred treatment for displaced femoral neck fractures in the elderly is hip arthroplasty, the treatment for impacted or undisplaced femoral neck fractures (UFNF) is still a subject of controversy. Our purpose was to systematically review studies of elderly patients with UFNF treated with internal fixation using screws: (i) what is the reported mortality; (ii) what is the reoperation rate; (iii) what are the clinical and radiological outcomes; and (iv) what is the methodological quality of the included studies?

Methods: This systematic review was performed through a search of PubMed and the Cochrane database using a structured search algorithm including studies enrolling patients older than 60 years old, with UFNF treated with internal fixation using screws. Our literature search returned 950 studies and 11 were selected for final abstraction.

Results: 6 studies reported mortality rate. At 1-year follow-up mortality was reported by 3 studies: 18.8%; 22%, and 19%. At 5 years, 1 study reported mortality rate of 42%. Overall reoperation rate was reported by 9 studies and ranged from 8%-19%, while conversion to hip arthroplasty was performed in the range between 8% and 16% according to 6 studies.

Conclusions: Internal fixation with cannulated screws for UFNF in the elderly is a valuable option, although it has substantial reoperation and mortality rates. Further prospective high-quality, randomised controlled trials are required to establish the optimal approach for the treatment of UFNF.
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http://dx.doi.org/10.5301/hipint.5000532DOI Listing
January 2018

Arthroscopic acetabuloplasty without labral detachment for focal pincer-type impingement: a minimum 2-year follow-up.

J Hip Preserv Surg 2017 Jul 12;4(2):145-152. Epub 2017 Apr 12.

Hip Surgery Unit, Carlos E. Ottolenghi, Institute of Orthopaedics, Italian Hospital of Buenos Aires, 4247 Potosi St., Buenos Aires 1199, Argentina.

In order to access and resect the acetabular rim, arthroscopic acetabuloplasty was described with labral detachment. When the chondrolabral junction remains intact, acetabuloplasty and labral refixation can be performed maintaining an unharmed labrum. We aimed to evaluate the outcome of a group of patients treated with arthroscopic acetabuloplasty without labral detachment. During the study period, we retrospectively analysed 44 patients with pincer-type o combined impingement and an intact chondroblabral junction, with an average follow-up of 32 months (range: 27-38). We excluded patients with isolated CAM-type impingement and previous hip pathology. Radiographs were analysed to define impingement and classify grade of osteoarthritis. Clinical evaluation consisted of pre-operative and post-operative modified Harris hip score (mHHS) and WOMAC as well as post-operative visual analogue scale (VAS) of pain and satisfaction. Reoperations were considered surgical failures for purposes of survival analysis. Mean mHHS changed from 51.06 (SD 4.81) pre-operatively to 84.97 (SD 12.79) post-operatively. Pre-operative WOMAC was 29.18 (SD 8) and post-operative, 13.10 (SD 11). Post-operative VAS was 7.5 and 2.27 for satisfaction and pain, respectively. When comparing patients with Tönnis 0 to those with Tönnis 1, the former showed better results regarding post-operative mHHS (89.9 s versus 77.85,  = 0.03), pain VAS (1.5 versus 6.3,  = 0.03) and satisfaction VAS (8.2 versus 6.3,  = 0.01). Survival was 100% at 24 months and 76% at 40 months (95% CI: 35-98%). Arthroscopic acetabuloplasty without labral detachment achieved good clinical outcomes. Slight degenerative changes on radiographs correlated with poorer clinical outcomes.
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http://dx.doi.org/10.1093/jhps/hnx015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467423PMC
July 2017

Long-term Outcome of Unconstrained Primary Total Hip Arthroplasty in Ipsilateral Residual Poliomyelitis.

Orthopedics 2017 Mar 14;40(2):e255-e261. Epub 2016 Nov 14.

Incapacitating articular sequelae in the hip joint have been described for patients with late effects of poliomyelitis. In these patients, total hip arthroplasty (THA) has been associated with a substantial rate of dislocation. This study was conducted to evaluate the long-term clinical and radiologic outcomes of unconstrained THA in this specific group of patients. The study included 6 patients with ipsilateral polio who underwent primary THA between 1985 and 2006. Patients with polio who underwent THA on the nonparalytic limb were excluded. Mean follow-up was 119.5 months (minimum, 84 months). Clinical outcomes were evaluated with the modified Harris Hip Score (mHHS) and the visual analog scale (VAS) pain score. Radiographs were examined to identify the cause of complications and determine the need for revision surgery. All patients showed significantly better functional results when preoperative and postoperative mHHS (67.58 vs 87.33, respectively; P=.002) and VAS pain score (7.66 vs 2, respectively; P=.0003) were compared. Although 2 cases of instability were diagnosed, only 1 patient needed acetabular revision as a result of component malpositioning. None of the patients had component loosening, osteolysis, or infection. Unconstrained THA in the affected limb of patients with poliomyelitis showed favorable long-term clinical results, with improved function and pain relief. Nevertheless, instability may be a more frequent complication in this group of patients compared with the general population. [Orthopedics. 2017; 40(2):e255-e261.].
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http://dx.doi.org/10.3928/01477447-20161108-03DOI Listing
March 2017

Primary Total Hip Arthroplasty With Fourth-Generation Ceramic-on-Ceramic: Analysis of Complications in 939 Consecutive Cases Followed for 2-10 Years.

J Arthroplasty 2017 02 10;32(2):480-486. Epub 2016 Aug 10.

The Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Background: Delta ceramics may be the bearing of choice for younger and active patients due to its improved toughness and wear characteristics, provided there is no risk of fracture. However, ceramic fracture is the most serious complication related to this type of bearing. Although millions of Delta ceramics have been implanted worldwide, short to midterm results have been scarcely reported in the literature. The purpose of this study was to report the complication rate at short to midterm follow-up associated with the bearing surface used in a series of primary total hip arthroplasties with Delta ceramic-on-ceramic bearings performed in a single institution.

Methods: A total of 939 cases (880 patients) undergoing primary total hip arthroplasty with fourth-generation Delta ceramic-on-ceramic bearings were retrospectively reviewed. They were followed for an average of 5.3 years (2-10 years).

Results: One hip experienced a liner fracture, 2 cups presented early loosening due to friction between the acetabular screw and the backside of the liner, one femoral ball head had a fracture; one case of squeaking was reported, which is impending revision. Considering revision or impending revision in relationship with the bearing surface as the end point, the mean survival rate was 99.3% (confidence interval 95%, 98.3%-99.7%) at 2-10 years.

Conclusion: This study showed a low rate of ceramic fracture compared with others; however, it was much higher than the complication rate presented by the manufacturers. The complications observed were directly related to technical errors that surgeons should avoid when using this type of surface.
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http://dx.doi.org/10.1016/j.arth.2016.07.032DOI Listing
February 2017

Hip arthroscopy in osteoarthritis: a systematic review of the literature.

Hip Int 2016 Jan-Feb;26(1):8-14. Epub 2015 Sep 14.

The Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Background: Hip arthroscopy treatment in patients with osteoarthritis is controversial.

Hypothesis/purpose: To systematically review the clinical outcome of patients with hip osteoarthritis (OA) treated with arthroscopy and what proportion of these patients subsequently underwent total hip arthroplasty (THA).

Study Design: Systematic review.

Methods: PubMed, Cochrane library and LILACS were searched from January 1990 through December 2013 for eligible studies. The methodological quality of the collected data (applied to each study) was performed with a modified version of the Coleman methodology score (mCMS).

Results: 11 studies were included in this review. Most of the studies included reported clinical improvements. The overall conversion rate to THA ranged from 9.5% to 50%. Mean time between arthroscopy and THA was 13.5 months.

Conclusions: The quality of studies is low. We have found inconclusive evidence to make categorical indications for hip arthroscopy in the treatment of OA, although we have found that there is some postoperative clinical outcome improvement of pain and function in a short-term evaluation. Increasingly worse outcomes were seen as the severity of OA increased.
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http://dx.doi.org/10.5301/hipint.5000299DOI Listing
January 2017

Skin staples versus intradermal wound closure following primary hip arthroplasty: a prospective, randomised trial including 231 cases.

Hip Int 2015 Nov-Dec;25(6):563-7. Epub 2015 Jun 27.

The Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Intradermal wound closure is controversial in primary total hip arthroplasty. Randomised, controlled trials in wound closure following a total hip arthroplasty (THA) are scarce. Our hypothesis was that skin staples closure would be related to a similar complication rate and operative time as intradermal closure with polypropylene. From September 2011 to May 2012, 231 THAs in 219 patients with an average age of 62 years old (range: 21-91) were performed. No differences were observed in both groups according to sex, age, BMI and comorbidities (p = 0,82). Cases were divided into 3 groups according to medical factors that influence wound healing: group 1 (no medical history, 70.5%), group 2 (diabetes, tobacco smokers, obesity, corticosteroids, rheumatoid disease, 25%) and group 3 (organ transplantation, neoplastic patients or 2 or factors of group 2, 4.5%). Once randomised using a computer-generated method, all patients remained within the group to which they were allocated to wound closure with skin staples (Leukosan® SkinStapler PTW-35, BSN, Germany) that were used in 112 THAs in 105 patients (48%), or continuous 3.0 intradermal non-absorbable polypropylene suture (Prolene™ 0, Ethicon Inc. Somerville, New Jersey, USA) in 119 THA´s in 115 patients (52%). A 3.8% wound complication rate was observed in this series, with a 2.1% complication rate for the group that was closed with skin staples and a 1.7% rate for the group with intradermal suture (p = 0.7). All the complications were treated conservatively except for one acute deep infection (0.4%) that was successfully treated with debridement, component retention and intravenous antibiotics. There were no differences in both groups related to operative time or wound length.In these series of primary elective THAs, skin staples were associated with a similar complication rate to an intradermal closure technique.
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http://dx.doi.org/10.5301/hipint.5000278DOI Listing
October 2016

Intraoperative synovial C-reactive protein is as useful as frozen section to detect periprosthetic hip infection.

Clin Orthop Relat Res 2015 Dec;473(12):3876-81

Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Potosí 4247, C1199ACK, Buenos Aires, Argentina.

Background: Synovial quantification of C-reactive protein (SCRP) has been recently published with high sensitivity and specificity in the diagnosis of periprosthetic joint infection. However, to our knowledge, no studies have compared the use of this test with intraoperative frozen section, which is considered by many to be the best intraoperative test now available.

Questions/purposes: We asked whether intraoperative SCRP could lead to comparable sensitivity, specificity, and predictive values as intraoperative frozen section in revision total hip arthroplasty.

Methods: A prospective study was performed including 76 patients who underwent hip revision for any cause. SCRP quantification (using 9.5 mg/L as denoting infection) and the analysis of frozen section of intraoperative samples (five or more polymorphonuclear leukocytes under high magnification in 10 fields) were performed in all the patients. The definitive diagnosis of an infection was determined according to the Musculoskeletal Infection Society (MSIS). In this group, 30% of the patients were diagnosed with infection using the MSIS criteria (23 of 76 patients).

Results: With the numbers available, there were no differences between SCRP and frozen section in terms of their ability to diagnose infection. The sensitivity of SCRP was 90% (95% confidence interval [CI], 70.8%-98.6%), the specificity was 94% (95% CI, 84.5%-98.7%), the positive predictive value was 87% (95% CI, 66.3%-97%), and the negative predictive value was 96% (95% CI, 87%-99.4%); the sensitivity, specificity, positive predictive value, and negative predictive value were the same using frozen sections to diagnose infection. The positive likelihood ratio was 16.36 (95% CI, 5.4-49.5), indicating a low probability of an individual without the condition having a positive test, and the negative likelihood ratio was 0.10 (95% CI, 0.03-0.36), indicating low probability of an individual without the condition having a negative test.

Conclusions: We found that quantitative SCRP had similar diagnostic value as intraoperative frozen section with comparable sensitivity, specificity, and predictive value in a group of patients undergoing revision total hip arthroplasty. In our institution, SCRP is easier to obtain, less expensive, and less dependent on the technique of obtaining and interpreting a frozen section. If our findings are confirmed by other groups, we suggest that quantitative SCRP be considered as a viable alternative to frozen section.

Level Of Evidence: Level I, diagnostic study.
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http://dx.doi.org/10.1007/s11999-015-4340-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4626517PMC
December 2015

Paradoxical cerebral fat embolism in revision hip surgery.

Case Rep Orthop 2014 11;2014:140757. Epub 2014 Aug 11.

Hip Surgery Unit "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Peron 4190, 1181 Buenos Aires, Argentina.

The incidence of clinical fat embolism syndrome (FES) is low (<1%) whilst fat embolism (FE) of marrow fat appears to occur more often (Mellor and Soni (2001)). Paradoxical brain FE may occur in patients undergoing hip orthopedic surgery who have an undocumented patent foramen ovale (PFO). We report a case of an eighty-year-old male patient, who underwent a scheduled revision hip surgery suffering a paradoxical cerebral FE.
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http://dx.doi.org/10.1155/2014/140757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4144387PMC
September 2014

Bone grafting and two-stage revision total hip arthroplasty.

Authors:
Martin A Buttaro

Hip Int 2012 Jul-Aug;22 Suppl 8:S69-74

Hip Surgery Unit, Institute of Orthopaedics Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires - Argentina.

Periprosthetic deep infection in combination with substantial bone loss is one of the most challenging situations in revision hip surgery. We believe the effective management of these patients requires infection control as well as bone reconstruction. A review of our previously published studies on antibiotic loaded bone allografts is presented in this paper. These investigations provided us with information on the use of bone allografts in combination with antibiotics in cases of previous infection. Our protocol is based on removal of implants, meticulous debridement, parenteral antibiotic therapy and a second-stage reconstruction with vancomycin-supplemented bone allografts to treat an infected hip arthroplasty. We observed that vancomycin does not affect bone allograft incorporation at concentrations that are 300 times higher than the minimum inhibitory concentration for Staphylococcus aureus and Staphylococcus epidermidis. We also obtained adequate pharmacokinetics using these composites, with high local levels without renal impairment. This method has the capacity of acetabular and femoral bone stock restoration, with sound fixation and without increasing the rate of reinfection.
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http://dx.doi.org/10.5301/HIP.2012.9573DOI Listing
February 2013

High failure rate with the GAP II ring and impacted allograft bone in severe acetabular defects.

Clin Orthop Relat Res 2012 Nov;470(11):3148-55

Hip Surgery Unit, Institute of Orthopaedics Carlos E Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Background: Reconstruction rings and bone allografts have been proposed to manage severe acetabular bone loss. However, a high early failure rate of the Graft Augmentation Prosthesis (GAP) II reinforcement ring (Stryker Orthopaedics, Mahwah, NJ, USA) has been reported in one small series.

Questions/purposes: We therefore determined (1) the survival of this device in combination with impacted morselized allograft bone in patients with severe defects and (2) the complication rate.

Methods: We retrospectively reviewed 24 patients (21 aseptic and three septic) with severe acetabular bone loss (10 hips with Type III defects and 14 with Type IV defects according to the American Academy of Orthopaedic Surgeons classification). We determined function and numbers of failures. The minimum followup was 24 months (mean, 34 months; range, 24-72 months).

Results: At latest followup, the reconstruction had failed in nine of the 24 patients: six with aseptic loosening, three with infection. The average postoperative Merle d'Aubigné-Postel score of the patients whose reconstructions had not failed was 16.6 points; at latest followup, these patients had radiographic evidence of incorporation and consolidation of bone allografts. Seven of the nine patients whose reconstructions had failed underwent reoperation. Fatigue fracture of the ring at the plate-cup union occurred in five patients at an average of 45 months postoperatively. All patients with failed reconstructions who underwent reoperation were treated with Trabecular Metal(™) (Zimmer Inc, Warsaw, IN, USA) cups and were functioning well at latest followup.

Conclusions: We observed a high rate (37%) of early catastrophic failures of the GAP II reconstruction ring, particularly in patients with Type IV defects. Due to this high failure rate, we have abandoned its use.

Level Of Evidence: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1007/s11999-012-2402-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462861PMC
November 2012

Squeaking in a Delta ceramic-on-ceramic uncemented total hip arthroplasty.

J Arthroplasty 2012 Jun 6;27(6):1257-9. Epub 2012 Mar 6.

Hip Surgery Unit, Institute of Orthopaedics Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.

Squeaking is one of the main concerns related to the use of ceramic-on-ceramic total hip arthroplasty. Although it has received much recent publicity, most of the previous reports on this complication have been related to the use of the second generation of alumina ceramics combined with a cup having an elevated metal rim to protect the ceramic liner from neck impingement. We report a patient with a third-generation Biolox Delta (CeramTec AG, Plochingen, Germany) ceramic-on-ceramic uncemented total hip arthroplasty without an elevated metal rim in the cup who presented with a squeaking hip at 23 months postoperative. Although this complication was mainly related to a specific design in the literature, this case demonstrates that newer generation of ceramics can also present squeaking.
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http://dx.doi.org/10.1016/j.arth.2012.01.005DOI Listing
June 2012

Incidence of deep infection in aseptic revision THA using vancomycin-impregnated impacted bone allograft.

Hip Int 2010 Oct-Dec;20(4):535-41

The Hip Centre, Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital in Buenos Aires, Buenos Aires, Argentina.

The addition of antibiotic to cement is a frequent practice in aseptic revision hip surgery There is concern about adding vancomycin to cement due to potential effects on mechanical properties and prolonged elution of subtherapeutic levels antibiotic. Bone allografts can store and provide high levels of vancomycin to surrounding tissues. We analyzed the incidence of infection after one-stage aseptic revision hip reconstruction utilizing acetabular and/or femoral vancomycin-impregnated impacted bone allograft and a THA fixed with cement containing no antibiotic. We hypothesized that the infection rate may be similar to that reported in the literature following traditional impaction grafting using antibiotic loaded cement. Seventy five consecutive patients (80 hips) with a preoperative Merle D'Aubigné and Postel functional score averaging 4.8 points were followed up for a mean of 36 months (range 24 - 59 months). The incidence of infection was 1.25% (CI 95%=96.26-100%). A deep infection (thought to be haematognous in origin) occurred in 1 patient 2 years after the index surgery. The average postoperative Merle D´Aubigne score was 16.2 points. The last radiographic evaluation demonstrated a less than 5 mm acetabular migration and a less than 5 mm femoral subsidence in all cases. Vancomycin-supplemented allografts restored bone stock and provided sound fixation with a low incidence of infection. This incidence of deep sepsis is similar to that reported with antibiotic-loaded PMMA but without the reported mechanical and pharmacological disadvantages.
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http://dx.doi.org/10.1177/112070001002000419DOI Listing
April 2011

Combining C-reactive protein and interleukin-6 may be useful to detect periprosthetic hip infection.

Clin Orthop Relat Res 2010 Dec;468(12):3263-7

Hip Surgery Unit, Institute of Orthopaedics Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Potosí 4215 (C1199ACK), Buenos Aires, Argentina.

Background: The sensitivity and specificity to detect periprosthetic infection of the different methods have been questioned, and no single laboratory test accurately detects infection before revision arthroplasty.

Questions/purposes: We asked whether preoperative C-reactive protein (CRP) and interleukin-6 (IL-6) could lead to similar sensitivity, specificity, and predictive values as our previous results obtained with intraoperative frozen section (FS) in revision total hip arthroplasty (THA).

Methods: We prospectively followed 69 patients who had undergone revision THA for failure of a primary THA. The definitive diagnosis of an infection was determined on the basis of positive histopathologic evidence of infection or growth of bacteria on culture.

Results: Eleven of the 69 hips were infected. The combination of an elevated CRP and IL-6 was correlated with deep infection in all the cases and showed a sensitivity of 0.57 (0.13-1.00), a specificity of 1.00 (0.99-1.00), a positive predictive value of 1.00 (0.87-1.00), and a negative predictive value of 0.94 (0.87-1.00). FS showed a sensitivity of 0.81 (0.54-1.00), a specificity of 0.98 (0.94-1.00), a positive predictive value of 0.90 (0.66-1.00), and a negative predictive value of 0.96 (0.91-1.00). Combining CRP and IL-6 provided similar sensitivity, specificity, and positive predictive values as the FSs.

Conclusions: Our data suggest the combination of CRP and IL-6 would be a useful serologic tool to complement others when diagnosing periprosthetic infection.
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http://dx.doi.org/10.1007/s11999-010-1451-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2974855PMC
December 2010

Impacted bone allografts and a cemented stem after failure of an uncemented stem: preliminary results.

Hip Int 2009 Jul-Sep;19(3):221-6

Hip Surgery Unit, Institute of Orthopaedics Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Argentina.

We reviewed the results of impaction bone grafting technique and a cemented stem in 27 consecutive patients with a failed uncemented femoral component. At an average follow-up of 55 months (25 to 94) none of the femoral components were removed or revised because of aseptic loosening or deep infection. In one hip a non progressive radiolucent line was observed in Gruen zone 5 with no clinical evidence of failure. The average postoperative Merle d'Aubigné and Postel Hip Score was 5.8 points for pain, 5.5 points for mobility and 5.4 points for gait. Revision of a failed uncemented stem with impaction grafting technique provided pain relief and improved function. The rate of success and restoration of bone stock were encouraging at mid-term follow-up.
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http://dx.doi.org/10.1177/112070000901900306DOI Listing
February 2010

Proximal femoral reconstructions with bone impaction grafting and metal mesh.

Clin Orthop Relat Res 2009 Sep 18;467(9):2325-34. Epub 2009 Mar 18.

Hip Surgery Unit, Institute of Orthopaedics Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Potosí 4215 (C1199ACK), Buenos Aires, Argentina.

Extensive circumferential proximal cortical bone loss is considered by some a contraindication for impaction bone grafting in the femur. We asked whether reconstruction with a circumferential metal mesh, impacted bone allografts, and a cemented stem would lead to acceptable survival in these patients. We retrospectively reviewed 14 patients (15 hips) with severe proximal femoral bone defects (average, 12 cm long; 14 type IV and one type IIIB using the classification of Della Valle and Paprosky) reconstructed with this method. The minimum followup was 20 months (average, 43.2 months; range, 20-72 months). Preoperative Merle D'Aubigné and Postel score averaged 4.8 points. With revision of the stem as the end point, the survivorship of the implant was 100% at one year and 86.6% at 72 months. The mean functional score at last followup was 14.4 points. We observed two fractures of the metal mesh at 31 and 48 months in cases reconstructed with a stem that did not bypass the mesh. Dislocation (3 cases) and acute deep infection (3 cases) were the most frequent complications. Patients with complete absence of the proximal femur may be candidates for biological proximal femoral reconstructions using this salvage procedure. Bone impaction grafting must be a routine technique if this method is selected.
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http://dx.doi.org/10.1007/s11999-009-0777-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866911PMC
September 2009

Acetabular revision with metal mesh, impaction bone grafting, and a cemented cup.

Clin Orthop Relat Res 2008 Oct 13;466(10):2482-90. Epub 2008 Aug 13.

Hip Surgery Unit, Institute of Orthopaedics Carlos E. Ottolenghi, Italian Hospital of Buenos Aires, Potosí 4215, C1199ACK, Buenos Aires, Argentina.

Unlabelled: Impaction grafting is controversial in the presence of segmental and cavitary acetabular defects and requires the use of supplemental devices to close segmental defects. This approach, however, would allow treating combined deficiencies that could not be managed with impacted cancellous bone alone. We raised the following two questions: (1) What is the survival rate in patients with combined deficiencies reconstructed with metal mesh, impaction grafting and a cemented cup and (2) can metal mesh prevent cup migration? We evaluated 23 cavitary uncontained acetabular defects in revision hip arthroplasty. Preoperative diagnoses were aseptic loosening (19 hips) and second-stage reimplantations after resection for infection (four hips). The preoperative Merle D'Aubigné-Postel score averaged 7.4 points. Two patients had reoperations for mechanical failure at 6 and 24 months. The survival rate with further revision as an end point was 90.8% at an average of 36 months (range, 24-56 months; 95% confidence interval, 68.1-97.6). Metal mesh did not prevent cup migration: migration occurred in all patients, averaging 5.1 mm (range, 2-25 mm). Another three patients with severe combined defects had asymptomatic mesh rupture with 3- to 15-mm migration. Postoperative functional score averaged 16.2 points. Metal mesh, impaction grafting, and a cemented cup should be considered for reconstruction of medium uncontained acetabular defects, but not for severe combined deficiencies.

Level Of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1007/s11999-008-0442-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2584278PMC
October 2008