Guideline for management of septic arthritis in native joints (SANJO)

This clinical guideline is intended for use by orthopedic surgeons and physicians who care for patients with possible or documented septic arthritis of a native joint (SANJO). It includes evidence and opinion-based recommendations for the diagnosis and management of patients with SANJO.

Medium-term results after total clavicle resection in cases of osteitis: a consecutive case series of five patients

PURPOSE

Claviculectomy is a rare and poorly described event in the surgical therapy of diseases of the clavicle. We present a case series and functional results of patients who underwent total claviculectomy.

METHODS

From 1995 to 2006 a total of 26 patients diagnosed with osteitis of the clavicle underwent surgery in our unit. Of these, five patients (all female) needed a total resection of the clavicle in order to ensure permanent healing from infection. The data collection was prospective. The data gathered preoperatively and at follow-up included clinical examinations, laboratory findings, radiographs and the Constant shoulder scores. The mean follow-up period was 7.5 months.

RESULTS

The surgical concept described was able to eliminate infection in all cases studied within an average hospital stay of 13.4 days (8-18 days). Only one patient showed complications; suffering from chronic pain syndrome requiring surgical revision. After total resection of the clavicle four of five patients showed very good functional results. The average Constant score showed a significant increase from 82 before surgery to 95 at follow-up.

CONCLUSIONS

The surgical technique described for total claviculectomy, along with the insertion of local antibiotic beads, was able to eliminate infection in every case. Good functional results and a low complication rates were observed. For good functional results and the permanent elimination of infection, adjacent joints have to be addressed, the periosteal tube should be preserved and early functional treatment is essential.

Surgical therapy of hip-joint empyema. Is the Girdlestone arthroplasty still up to date?

PURPOSE

Hip-joint empyema is a severe local infection that can cause general illness and, in the worst-case scenario, death by septic complications. For severe hip-joint infections, the Girdlestone arthroplasty has been an established treatment option for many decades. We describe functional midterm results after treatment of haematological and postoperative hip-joint infections.

METHODS

From 2000 to 2010, 24 patients underwent surgical treatment for 27 hip-joint empyemas. The surgical procedures included radical debridement, implantation of local antibiotic beads and soft tissue management. Besides clinical, laboratory and imaging parameters, we analysed the Harris hip score (HHS).

RESULTS

Twenty-three patients (26 hips) were followed up after a mean of 30 (3.1-126.8) months. The study group consists of 12 men and 11 women, with an average height of 1.71 m, weight of 84.7 kg and body mass index (BMI) of 28.6 kg/m(2). Hip-joint empyema was due to haematological septic spread in eight patients, surgery related in 12 hips and other causes in six cases. One patient died due to septic complications during the hospital stay. Intraoperative bacterial culture was positive in 50%, with Staphylococcus aureus as the most common organism (n = 11). Average hospital stay was 35 days. HHS significantly improved from 18.2 preoperatively to 47.8 at follow-up. Functional results were mainly poor, but pain relief increased significantly. The infection control rate was 96% with four (15%) complications.

CONCLUSION

Resection arthroplasty by Girdlestone is able to control infection in most cases with an acceptable complication rate but poor functional results. In conclusion, the Girdlestone arthroplasty still is an essential surgical strategy for treating hip-joint empyema in cases in which functional outcome is of lesser priority.

[Medium-term results of surgical treatment for osteitis of the clavicle]

AIM

Osteitis of the clavicle is rare and not well described in the international literature. We describe a concept of surgical treatment with medium-term observations.

METHOD

A total of 22 patients (12 women, 10 men; BMI Ø 24.6 kg/m(2), age Ø 48 years) with osteitis of the clavicle were included in the series. The treatment regime consisted of a surgical approach. Data collection was prospective. Data gathered preoperatively and at follow-up included clinical examination, laboratory findings, radiographs and the Constant scoring system. The mean follow-up period was 13.3 (3-53) months.

RESULTS

The described surgical concept was able to permanently eliminate infection in all cases studied. Surgical revisions were required in six patients. The average Constant score showed a significant increase from 66 to 84 at follow-up. Patients also showed good functional results after total resection of the clavicle.

CONCLUSION

The reported treatment regime provides reliable results in terms of eliminating infection with good clinical results. Neighboring joints were frequently also involved in the infection and needed to be surgically addressed.

[Mechanoreceptors in the distal aspects of the m. vastus medialis?]

Five cadavers were fixed in Jores' solution and alcohol. The distal parts of the medial vastus muscle and the medial parts of the patella ligament and of the capsule of the knee joint were prepared and histologically examined. Previous examinations had shown mechanoreceptors in the knee joint ligaments; the present study was designed to find whether mechanoreceptors could be identified in the anatomical structures mentioned, in which case an arthrotomy by the Payr access would interrupt the muscle reflexes. Only some mechanoreceptors in the medioventral parts of the knee joint capsule close to the tendon of the great muscle could be identified. Thus, when the Payr access is used there is no interruption of the sensibility transmitted by proprioceptors.

Functional construction of the sacroiliac ligamentous apparatus

The sacroiliac ligamentous apparatus was examined as a part of a biomechanical pelvis-lower extremities system. The ligamentous apparatus of two pelves was freed, and the findings concerning the ligaments and their direction were drawn by a modular constructed, three-dimensional calculator model of the pelvic region. The ligamentous apparatus of the sacroiliac joint belongs to a functional system. Its task is to minimize every movement in this amphiarthrosis. The ligamentous apparatus shows an adaptation to strong or long-time-acting stresses. The junction between the os sacrum, pelvis and the ligamentous apparatus of the sacroiliac joint can be described as self-tightening. Local stresses are also reduced by the ligaments. A loosening in this system, which has to fix the os sacrum to the pelvic girdle, leads to a static insufficiency. The consequence is pain due to an irritation of the lumbosacral trunk. The exact description of the structure allows a representation according to the laws of similarity mechanics. With such a representation one can build up a computer-aided biomechanical model of the pelvis-lower extremities region. Examples for such a model are biomechanical finite-element models. By observing the laws of similarity mechanics (an exact description of geometric, physical and functional conditions) an efficient biomechanical model can be constructed that also takes into consideration the complex functional circumstances, in contrast to previous models. In order to construct such a model, one has to feed the findings of the examination into a data bank, which has to be demanded.

Functional construction of the superficial and deep fascia system of the lower limb in man

The muscular system, the connective tissue and the bones are the components of a biomechanical pelvis-lower extremity model. The occasional electrical events in the muscles were not taken into account, as they can only be measured by physiological methods. In this publication, the connective tissue of the lower extremities is examined. The connective tissue system of the thigh and leg was prepared; after removal of the muscles the so-called 'hollow' lower extremity could be studied. A topographical documentation followed, and the structure and directions of the fibers were observed with polarized light. The connective tissue systems of the lower extremities and bones form a biomechanical, effective and functional system, the bone-fascia-tendon system. The components of the connective tissue in such a system are the fascia lata, the crural fascia, the iliotibial tract, the femoral and crural intermuscular septa, and the membrana interossea. The iliotibial tract is not the sole part of this system having a tension band effect, other components--above all the lateral femoral intermuscular septum--also reduce the forces acting on the bones. Therefore, the tensile strength of the iliotibial tract has to be considered lower as supposed. The iliotibial tract is not a part of the fascia lata; it is an independent, vertically tightened tendon of the 'pelvic deltoid muscle' (gluteus maximus, tensor fasciae latae). The iliotibial tract passes over the greater trochanter like on a roller bearing. It is not attached directly to the greater trochanter and to the lateral femoral condyle, so that previous models have to be modified. The iliotibial tract glides in a fascia bag which is composed of oblique and horizontal fibers of the broad fascia. The iliotibial tract, as tendon of the pelvic deltoid muscle, continues in a lateral location into the leg where it is fixed to the lateral malleolus. The present report provides a new description of the structure of the connective tissue system of the lower extremities. The model reported complies with the laws of similarity mechanics by describing exactly the geometric, physical and functional conditions. This representation could facilitate the construction of a computer-aided, efficient, biomechanical model of the pelvis-lower extremity region considering also the complex functional circumstances, in contrast to previous models. In order to construct such a model, the data obtained by the examination of the connective tissue of the lower extremities have to be given into a data bank, which, however, has to be built up.