1	Complications of Hip Surgery
2	Special Problems in RA Polysystemic Polypharmacy Polyarticular Creeping substitution Rehab difficult Death (SMR1.48) Lie Acta Orth Scand 2000 71 19-27 Anaemia Epo Matsuda et al Orthopaedics 24(1) 41-4 2001
3	Complications of Hip Replacement Surgery Thromboembolism Dislocation Heterotopic ossification Aseptic Loosening Sepsis
4	Complications Thromboembolism 13% bleeding with LMWH Van Heereveld et al Ann Rheum Dis 60(10) 974-6 2001 Dislocation No difference (Scottish Arthroplasty Project) Heterotopic ossification Lower in RA Eggli Arch Orthop Trauma Surg 2001 121 (9) 531-5
5	Aseptic Loosening Initial interlock Bone metabolism 79 % survival at 25 years (Sochart/Porter1998 Lehtimaki J Arth 199 14 657-61) Increased loosening Ahnfelt Acta Orth Scand 1990 61 238 1-26 (Swedish Arth Register) No Difference Furnes JBJS 83B 2001 579-586 (Norwegian Arth Register)
6	Revision for Aseptic Loosening Acetabulum 2.6 – 8.4% Femur OA = RA RA worse than OA but age correction equal
7
8	Cemented Femoral Failure in RA 2% aseptic femoral loosening 10 Years Creighton et al JBJS A 80 1439 1998 (Iowa) 10% femoral loosening at 15 years Lehtimaki et al J Arth 14 657 1999 (Finland) 15% aseptic femoral loosening 25 years Sochart Porter JBJS A 79 1599 1997 (Wrightington)
9	Uncemented? Osteoporosis Cups good Stems poor Thomasen J Arth 16(5) 628-34 2001 Stems Promising Keisu J arth 2001 16 415-21 “Excellent” Effenberger Arch Orth Tr Surg 2002 122 80-7 Failure dependant on implant Schroeder-Boersch Orthopaede 1998 27 333-40
10	Protrusio Reconstruct centre of rotation Better interface Medialised loosening (Poss 1984)
11	Cemented Femoral revision in RA 45/47 “secure” 4% failure at 7 years Raut et al JBJS B 76 909 1994 6.9% failure at 8.5 years (type 2 femurs) Pierson Harris JBJS B 76 40 1994
12	Acetabular revision 90% survival 8 years impaction grafting Schreurs JBJS A 2003 85 647-52 Uncemented low risk surviving 44% at 8 yrs Mont Clin Orth 2002 400 140-8 Cement “not very encouraging” Raut JBJS A 78 1853-6
13	Complications Infection Early deep 1.8 x OA Poss et al Clin Orth 182 109 2-4 x late Freeman et al Clin Orth 95: 224 Immunosuppression Acute pre op infection “No difference” Scottish Arthroplasty report 2004 Espehaug Acta Orth Scand 1997 68 207-15
14	DMARDS and Infection Alone small increase in infections but are life threatening Moreland Pharmacoeconomics 2004 22 39-53 Phillips Arthitis Rheum 2002 47 17-21 Combinations additive Hansen Arthritis Rheum 2004 15 51 228-32 Primary no evidence for stopping Hip Foot Bibbo; Foot Ankle 2004 25 331-5 Revisions - discontinue
15	Diagnosis Of Infection in RA 52 RA revisions 9 infected Hansen protocol ESR >30 30% infected ESR<30 95% not infected CRP >20 25% infected CRP> 20 90% not infected Aspiration Positive 100% infected Negative 70% not Inf
16	Diagnosis Of Infection in RA Histology +ve 50% Infected -ve 95% not Inf PCR +ve 25% infected -ve 90% not Inf
17	Radiographic changes Periosteal reaction Fitzgerald RH Orth Clin N Am 1992 23 259-64 Early osteolysis Huddlestone HD J Arth 1988 3 285-97 91% loosening Lyons CW Clin Orthop 1985 195 239-51
18	Imaging Tech/Ind Bone scan 79% Sens 83% Spec Itasaka T J Orthop Sci 2001 6(4) 320-6 -ve rules out infection Terhanzedeh J Clin Nuc Med 1988 13 229-36 Indium WCC scan 80% Sens 100% spec Oyen et alJ Nuc Med 32 1991 1854-60 FDG Pet scan Sens 90% Spec 89% Zhuang H J Nuc Med 2001 42 44-8
19	Imaging 2 Ultrasound all have effusions AJ Radiology 1994 163 (2) 381-4 MRI “routine use not supported by data” Joseph TN J Arth 2001 16(6) 753-8 Labelled Cefuroxime 85% Sens 92% spec Yafar Z Eur J Nuc Med 2001 28(7) 822
20	Diagnostic Summary Negative inflammatory markers helpful Imaging unhelpful (other than radiograph) Positive aspiration microbiology good Negative histology useful PCR no better than existing tests Suspicion
21	Infection “Staging Systems” Organism Time and timing Host response 2 or more (Diabetes; Cardiac; Tobacco; Immune suppression etc) Limb viability
22	Practical……………………. +ve intra op culture 6 weeks antibiotics
23	Practical…………………… Early well fixed Debridement Antibiotics
24	Results..Suppresive antibiotics 50% retained for 3 years Medically unfit Physically unfit Known organism
25	Results….Debridement 71% success if< 1 month Early Well fixed Uncemented results poor
26	Practical…………………….. Loose / Late 2 stage + spacer ?1 stage
27	Results .. 1 Stage revision 82% success Radical debridement Sensitive organism Prolonged antibiotics Cemented Cost effective
28	Results ..2 Stage 91% success
29	Results .. 2 Stage + spacer 91% success Resistant organism Loose hip ? Reimplant time
30	Interprosthetic Fracture Internal fixation “all fail” Kenny J Arthroplasty 1998 13 361-4 Bone metabolism Fatigue or trauma? Listen to the bones
31	Conclusion Reconstruction may be necessary Late infection more common Difficult to diagnose Disease process as well as mechanical failure