Publications by Year: 2025

AIMS: Following resection of a primary bone tumour, reconstruction is commonly performed using either a megaprosthesis or biological reconstruction. Periprosthetic joint infection (PJI) remains one of the most frequent complications. Various treatment strategies exist for PJI, including debridement, antibiotics, and implant retention (DAIR), and single- and two-stage revision, although consensus on optimal management remains elusive. This study aimed to investigate the global practices regarding DAIR in tumour cases through an electronic survey among orthopaedic oncology surgeons.

METHODS: A global cross-sectional observational survey study was distributed to 272 orthopaedic oncology surgeons who attended the BOOM Consensus Meeting in January 2024. The survey contained 19 multiple choice questions focusing on DAIR practices. Responses were collected anonymously and analyzed using descriptive statistics.

RESULTS: The survey was completed by 173/272 surgeons (64%) from 44 countries. While 62% (169/272) routinely performed radical soft-tissue debridement in DAIR, only 39% exchanged all modular components, indicating variability in surgical approaches. DAIR was more commonly performed in acute rather than chronic infections, with 55% finding it very useful in acute cases. The use of local antibiotic delivery was supported by 56%, although only 49% found antibiotic cement coatings beneficial. Systemic antibiotic duration post-DAIR varied, with 39% favouring six weeks and 35% preferring three months.

CONCLUSION: The study highlights global inconsistencies in DAIR practices for PJI in orthopaedic oncology, with financial disparities impacting modular component exchange. Standardized definitions are lacking, and we propose that if only polyethylene is changed, then the procedure is referred to as 'poly exchange'; we recommend defining the procedure as DAIR when extensive debridement, lavage, and removal, wash, and reimplanting of all modular components is done while retaining stable stems, followed by suppressive antibiotic therapy; and finally, we recommend that if all the modular components are changed for new ones, the procedure is referred to as 'DAIR plus'.

BACKGROUND: The orientation of the acetabulum in the axial and coronal planes is well studied in the pathogenesis of impingement and instability of the hip. In contrast, the sagittal orientation of the acetabulum (SOA) is not well understood.

PURPOSE: To determine (1) the SOA in a large cohort of mature hips and (2) to assess the relationship between the SOA and acetabular version, acetabular center-edge angles (CEAs), and spinopelvic alignment.

STUDY DESIGN: Descriptive laboratory study.

METHODS: A total of 3695 patients (7390 mature hips) who underwent computed tomography (CT) scans for assessment of nonorthopaedic abdominal and pelvic conditions were studied. An automated measurement software was utilized to reconstruct 3-dimensional models from CT scans and to measure the SOA, functional SOA (not neutralizing pelvic position on sagittal plane), acetabular version, as well as acetabular CEAs and spinopelvic alignment, including the pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI).

RESULTS: The SOA was on average (± SD) 19.6°± 7.5°. The functional SOA (not neutralizing pelvic position on sagittal plane) was on average (± SD) 20.5°± 5.7°. The functional SOA had a statistically significant but negligible correlation with PI (r = 0.13; P < .001) and SS (r = -0.06; P < .001), and a weak positive correlation with PT (r = 0.23; P < .001). The SOA had a positive moderate correlation with the cranial (r = 0.41; P < .001) and central acetabular version (r = 0.39; P < .001) and a strong correlation (r = 0.63; P < .001) with caudal acetabular version. A 10° increase in SOA was associated with a 6.6° increase on the caudal acetabular version. The SOA had a moderate negative correlation (r = -0.48; P < .001) with the CEA at 3 o'clock (anterior for left and right hips). A 10° increase in SOA was associated with a 4.9° decrease in CEA at 3 o'clock.

CONCLUSION: The acetabulum is on average 19.5° cephalically oriented in the sagittal plane in asymptomatic individuals. The SOA correlates with acetabular version and cannot be presumed based on spinopelvic alignment.

CLINICAL RELEVANCE: The assessment of the SOA may aid in the diagnosis of hip impingement and instability, allowing a more precise correction of the acetabulum in hip arthroscopy and osteotomies.

AIMS: The aim of this study was to achieve consensus for important topics related to periprosthetic infection (PJI) in orthopaedic oncology, and to identify areas for future research.

METHODS: In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) held in Birmingham, UK, gathered 309 delegates from 53 countries to debate 20 consensus statements on PJI in orthopaedic oncology using a modified Delphi process.

RESULTS: Of 20 questions and statements on PJI in orthopaedic oncology, none achieved unanimous consensus, 18 achieved strong consensus, one achieved moderate consensus, and one achieved weak consensus. The statements that reached consensus with notable agreement were on the prophylaxis of infection, management of leaking wounds, and surgical strategies for the treatment of PJI. Short-duration antibiotic prophylaxis was deemed as effective as longer courses for lower-risk reconstructions, and aggressive management was recommended for wounds draining beyond five to seven days to prevent deep infection. Furthermore, single-stage, two-stage, and 1.5-stage revision were recognized as valid strategies, with two-stage revision remaining the most reliable. The statements that did not achieve consensus were on the role of debridement, antibiotics, and implant retention and prolonged antibiotic use post-revision.

CONCLUSION: The BOOM meeting achieved consensus for important topics on periprosthetic infection in orthopaedic oncology, but highlighted the low quality of the underlying evidence. This study has provided recommendations for the treatment of leaky wounds, duration of postoperative antibiotic prophylaxis, and choice of revision strategy.

BACKGROUND: Metallosis is a well-described complication of total hip arthroplasty (THA); however, its impact on periprosthetic joint infection (PJI) diagnosis and treatment remains unknown. We assessed whether coexisting metallosis at the time of revision THA is associated with delayed diagnosis and poorer PJI treatment outcomes.

METHODS: We retrospectively reviewed patients undergoing revision THA due to chronic and acute hematogenous PJI with coexisting metallosis (metallosis and PJI group). A matched cohort of patients with chronic and acute hematogenous PJI without metallosis was established (control group). The 2018 International Consensus Meeting criteria were used to define PJI. Metallosis was diagnosed based on the intraoperative findings or serum chromium/cobalt levels. The primary outcomes were culture positivity and survival free of reoperation or revision. Thirteen and 42 patients were included in the metallosis and PJI and the control groups, respectively.

RESULTS: The initial set of cultures was negative in 38% of patients in the metallosis and PJI group, compared to only 12% in the control group (P = .03). Time elapsed between presentation of symptoms and first positive culture was significantly longer in the metallosis and PJI group compared to the control (14.5 vs 0 days, P < .001). The revision rate was 46% in the metallosis and PJI group and 24% in the control group (P = .12). Revision-free survival in patients treated with debridement, antibiotics, and implant retention was 28% in the metallosis and PJI group and 79.7% in the control group, (P = .21).

CONCLUSIONS: Metallosis may increase the likelihood of initial false negative culture results and delay PJI diagnosis in patients undergoing revision THA.