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Lyme arthritis, one of the possible late manifestations of Lyme borreliosis, predominantly affects the supporting joints and in adults most often occurs in the form of monoarthritis of the knee. Early diagnosis is based on clinical findings and serology. PCR detection of Borrelia in synovial fluid has become an integral part of the laboratory testing algorithm. The clinical presentation and inflammatory markers in Lyme arthritis can resemble septic arthritis. Determining the levels of alpha-defensins (human neutrophil peptide (HNP 1-3)) in synovial fluid by liquid chromatography is a highly sensitive method revealing the presence of inflammatory process. Between 2020 and 2022, we examined eleven patients with Lyme arthritis of the knee. We measured levels of HNP 1-3 from synovial fluid by HPLC in patients, and we compared it with the corresponding C-reactive protein (CRP) levels in paired serum samples. In patients diagnosed with Lyme arthritis, HNP 1-3 levels in synovial fluid ranged from 2.5 to 261 mg/L, with a median of 46.5 mg/L. Average serum CRP was 43 mg/L. The results show that elevated HNP 1-3 can be consistent with not only septic arthritis or systemic disease, but also with Lyme arthritis, especially in patients with negative culture and 16S PCR from synovial fluid. Final diagnosis must be verified by examination for anti-Borrelia antibodies from serum and synovial fluid. The aim of this work is to introduce an HPLC method for the determination of alpha-defensins as one of the possible diagnostic markers.

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BACKGROUND: The diagnosis of joint replacement infection is a difficult clinical challenge that often occurs when the implant cannot be salvaged. We hypothesize that the pH value of synovial fluid could be an important indicator of the inflammatory status of the joint. However, in the literature, there is a lack of data on the pH changes in hip and knee joint replacements and their relation to infection and implant failure. In this study, we aimed to measure the pH levels of synovial fluid in patients with hip and knee joint replacements. We also investigated the potential of pH measurement as a diagnostic tool for joint replacement infection. In this study, we recorded the pH values to be 7.55 and 7.46 in patients where Pseudomonas aeruginosa was identified as the cause of the prosthetic joint infection. We attribute this to the different environments created by this specific bacterium. In other cases where the pH was higher, chronic mitigated infections were diagnosed, caused by strains of Staphylococcus aureus, Streptococcus agalactiase, and coagulase negative staphylococcus. MATERIALS AND METHODS: In our cohort of 155 patients with implanted hip (THA; n = 85) or knee (TKA; n = 70) joint replacements, we conducted a prospective study with a pH measurement. Out of the whole cohort, 44 patients had confirmed joint replacement infection (28.4%) (44/155). In 111 patients, infection was ruled out (71.6%) (111/155). Joint replacement infection was classified according to the criteria of the Musculoskeletal Infection Society (MSIS) from 2018. Based on the measured values, we determined the cut-off level for the probability of ongoing inflammation. We also determined the sensitivity and specificity of the measurement. RESULTS: The group of patients with infection (n = 44) had a significantly lower synovial fluid pH (pH = 6.98 ± 0.48) than the group of patients with no infection (n = 111, pH = 7.82 ± 0.29, p < 0.001). The corresponding median pH values were 7.08 for the patients with infection and 7.83 for the patients with no infection. When we determined the cut-off level of pH 7.4, the sensitivity level of infected replacements was 88.6%, and the specificity level of the measurement was 95.5%. The predictive value of a positive test was 88.6%, and the predictive value of a negative test was 95.5%. CONCLUSIONS: Our results confirm that it is appropriate to include a pH measurement in the diagnostic spectrum of hip and knee replacements. This diagnostic approach has the potential to provide continuous in vivo feedback, facilitated by specialized biosensors. The advantage of this method is the future incorporation of a pH-detecting sensor into intelligent knee and hip replacements that will assess pH levels over time. By integrating these biosensors into intelligent implants, the early detection of joint replacement infections could be achieved, enhancing proactive intervention strategies.

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Polymethylmethacrylate (PMMA) bone cement mixed with antibiotics is used in orthopedic surgery to cope with implant-related infections which are typically associated with the formation of bacterial biofilms. Taking into account the growing bacterial resistance to current antibiotics, we examined here the efficacy of a selected antimicrobial peptide (AMP) mixed into the bone cement to inhibit bacterial adhesion and the consequent biofilm formation on its surface. In particular, we followed the formation of bacterial biofilms of methicillin-resistant Staphylococcus aureus (MRSA) on implants made from PMMA bone cement loaded with AMP composed of 12 amino acid residues. This was evaluated by CFU counting of bacteria released by sonication from the biofilms formed on their surfaces after these implants were retrieved from the infected murine femoral canals. The AMP loaded in these model implants prevented adhesion of MRSA and the subsequent formation of MRSA biofilm on the surfaces of more than 80% of these implants, whereas biofilms did form on control implants made from the plain cement. The results of our experiments performed in the murine femoral canal indicate the potential for this murine osteomyelitis model to mimic actual operations in orthopedics.

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INTRODUCTION: The goal of this study was to investigate prevalence and morphometric parameters of pubic ligaments and the interpubic disk and its cavity using imaging methods for use in clinical medicine. METHODS: Pubic symphysis morphology was investigated in 652 patients (348 women and 304 men), from which 449 CT scans and 203 MR scans were available. The average age of men was 48 years and women 39 years. Investigated parameters included dimensions of the interpubic disk, visibility and width of the reinforcing ligaments, and visibility, dimensions, and location of the symphysial cavity. The results were compared with MR scans of 20 healthy volunteers and 21 dissected anatomic specimens. RESULTS: The craniocaudal, ventrodorsal, and mediolateral diameters of the pubic disk were 36 to 37.7, 14.8 to 15.2, and 2.2 to 4.2 mm in women and 42 to 42.3, 18.6 to 19, and 2.4 to 4.5 mm in men, respectively. Higher age correlated with shorter mediolateral diameter and larger craniocaudal and ventrodorsal diameters. The superior pubic ligament was visible in 93.1% of men (1.44 mm thick) and in 100% of women (1.7 mm); the inferior pubic ligament in 89.7% of men (1.74 mm) and 88% of women (1.95 mm), the anterior pubic ligament in 96.6% of men (1.5 mm) and 82% of women (1.34 mm); and the posterior pubic ligament in 65.5% of men (1.18 mm) and 63.7% of women (0.83 mm). A symphysial cavity was found in 24% of men and 22.9% of women, with craniocaudal, ventrodorsal, and mediolateral dimensions of 13, 10.7, and 3.2 mm in men and 9.5, 10.7, and 3 mm in women, respectively. CONCLUSION: The presented morphologic parameters provide an anatomic reference for diagnostics of pathologic conditions of the pubic symphysis. The following anatomic structures should be added to the official anatomic terminology: symphysial cavity (cavitas symphysialis), retropubic eminence (eminentia retropubica), anterior pubic ligament (ligamentum pubicum anterius), and posterior pubic ligament (ligamentum pubicum posterius). LEVEL OF EVIDENCE: II-III.

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The α-defensins (AD) present in synovial fluid have been regarded as constituting the most accurate periprosthetic joint infection (PJI) biomarker. The methods most commonly used for estimating AD as a biomarker are the qualitative Synovasure® PJI tests, based on the technique of lateral flow, and quantitative enzyme-linked immunosorbent assay (ELISA). Here, we propose a novel test based on detecting α-defensins in synovial fluid by high-performance liquid chromatography (HPLC). Synovial fluid was collected from 157 patients diagnosed with PJI, infectious arthritis (IA), arthrosis, reactive arthritis, and rheumatoid arthritis. AD concentrations in the fluid were determined by HPLC, and these same samples were used for additional diagnostic analyses. The results were statistically processed to calculate cutoff concentrations for PJI and IA. HPLC testing showed a sensitivity of 94% and a specificity of 92% for diagnosis of PJI, and a sensitivity of 97% and a specificity of 87% for diagnosis of IA. Using HPLC, we detected in synovial fluid a combination of three α-defensins: human neutrophil peptides HNP1, HNP2, and HNP3. All measured AD concentration values shown in this work refer to the sum of these three individual concentrations. Our study shows that the HPLC method meets the conditions for measuring precise concentrations of the sum of AD and can be recommended as part of a diagnostic array for PJI and IA diagnostics. By this method, we have verified that higher levels of AD in synovial fluid can also be seen in rheumatoid illnesses, crystal arthropathies, and reactive arthritis.

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BACKGROUND: The Lapidus procedure has been used for hallux valgus deformity correction since 1931. In some cases, the arthrodesis results in an unfavourable lateral inclination of first metatarsal head articular surface. The objective of our study was to evaluate the change of orientation of this articular surface in relation to the second metatarsal axis by comparing pre- and postoperative radiographs. The secondary target was to evaluate possible benefits of combination of Lapidus and Akin procedures in the reduction of hallux valgus deformity. METHODS: We evaluated 449 pre- and postoperative radiographs of 134 operations from 2010 to 2015. Routinely used angle measurements were performed on all X-rays. A sum of tangential angle to the second axis and distal articular set angle values was chosen as the best indicator for the deformity correction success. RESULTS: The mean value of these angles total was 5.2° ±9.3° before and 14.2° ±7.8° after the operation. In the group of patients, where the additional Akin osteotomy was used, the mean value was 5.3° ±8.4° before and 6.9° ±10.2° after the surgery. The mean difference in values between the two groups (with and without Akin procedure) was 7.3° of extra correction in favour of the group with the Akin osteotomy. CONCLUSIONS: The mean worsening of the tangential angle after Lapidus operation was 6.1° ±6.9°, which counts for significant deterioration after a surgery. The Akin osteotomy was found to be a valuable addition to the Lapidus arthrodesis, which improves the position of articular surfaces in first metatarsophalangeal joint.

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Joint replacement infections and osteomyelitis are among the most serious complications in orthopaedics and traumatology. The risk factors for these infections are often bacterial resistance to antimicrobials. One of the few solutions available to control bacterial resistance involves antimicrobials, which have a different mechanism of action from traditional antibiotics. Antimicrobial peptides (AMP) appear to be highly promising candidates in the treatment of resistant infections. We have identified several AMP in the venom of various wild bees and designed analogues that show potent antimicrobial activity and low toxicity against eukaryotic cells. The aim of the present study was to test the efficacy of one of those synthetic peptide analogues for the treatment of acute osteomyelitis invoked in laboratory rats. Femoral cavities of 20 laboratory Wistar rats were infected with Staphylococcus aureus. After 1 week, eight rats received an injectable calcium phosphate carrier alone, another eight rats were treated with a calcium phosphate mixed with AMP, and four rats were left without any further treatment. After another week, all rats were euthanized and radiographs were made of both the operated and healthy limbs. The animals with the carrier alone exhibited more severe acute osteomyelitis on radiographs in comparison to the recipients of the calcium phosphate carrier loaded AMP and untreated infected individuals. Based on the results of the above mentioned experiment, it was concluded that when injected directly into the site of femoral acute osteomyelitis, the calcium phosphate carrier mixed with AMP reduced osteomyelitis signs visible on radiographs.

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BACKGROUND: Preoperative planning with the aid of imaging methods is a principal factor in successful surgery on the shoulder. This work aims to evaluate the variability of glenoid version, spiralling twist and scapular inclination in relation to the frontal axis. Studies focusing on measuring the variability of scapular inclination in the standardised rest position are lacking in the literature. METHODS: We evaluated 104 CT scans of the shoulder. We measured the glenoid version with respect to the scapular axis at three levels. We measured the scapular inclination angle in relation to the sagittal plane and we determined scapular inclination in relation to the frontal axis. Statistical evaluation was performed using the marginal linear model and parameters were estimated using the generalised least squares method, which enables the dependency of measurements performed on the same subject to be taken into consideration. RESULTS: The highest values of retroversion are attained by the glenoid in the cranial section (average -9.96°, range -29.7 to +13.2°). Proof of the spiralling twist is the decline in retroversion at the centre of the glenoid (average -2.09°, range -16.7 to +11.6°). Retroversion decreases further in the inferior direction (average -0.5°, range -20.9 to +17.5°). The average thoracoscapular angle is 45.46°, ranging from 13.1 to 69.0°. The average scapular inclination in relation to the frontal plane is 44.54°, ranging from 21.0 to76.9°. CONCLUSIONS: During preoperative planning, the surgeon should take into consideration not only the glenoid version in relation to the scapular axis, but also the value of the scapular inclination so as to eliminate possible surgical errors, optimise prosthesis implantation and thus decrease the risk of functional restrictions of the joint. CLINICAL TRIAL REGISTRATION: Ethics Committee for Multi-Centric Clinical Trials (EK-554/14,29thApril 2014).

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The introduction of artificial joint replacement constitutes a breakthrough method of treatment for severe joint disease for millions of people worldwide.Annual increase in the number of primary replacement and also increasing demands on the longevity of joint replacements are leading to increased demands on wear resistance of articular surface. Ultra-high molecular weight polyethylene (UHMWPE) is still most commonly used material for the production of articular surface. It was introduced into clinical practice in the 60s of the 20th century. Physical-chemical properties of UHMWPE are subject of many studies. These lead gradually to its improvement in terms of higher wear resistance while maintaining the stability against oxidative degradation.The main objective of this review is to summarize the basic properties of high-molecular weight polyethylene which are important for its use in orthopaedic practice and to explain the possibilities of its modification and sterilization. Knowledge of the latest trends about this material helps to orthopaedic surgeons get oriented in the issues and then to choose for their patients implants with the highest implant longevity.

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INTRODUCTION: The main purpose of this study is to evaluate the efficacy of the plasma sprayed, combined porous titanium alloy/HA coating in promoting bony ingrowth and mechanical stabilization of total hip implants. The performance of the titanium alloy/HA type coated hip prostheses and the one of the same shape but without any coating, is compared in this paper. MATERIAL AND METHODS: The implants were manufactured from titanium alloy VT-6 (ASTM F-136). The hip stems utilized in the control group were identical to those subsequently coated. The coating consists of a plasma deposited first layer of porous titanium alloy (TiAl(6)V(4)), similar in composition to the forged substrate and a plasma deposited second layer of over-sprayed hydroxyapatite, Ca(10)(PO(4))6(OH)2. Coating is located in the critical area of the hip stems, where high fixation interface strength is desired, i.e. in the proximal area of the stem where the highest stresses occur. The porous titanium alloy/hydroxyapatite (HA) coated femoral stems were implanted in 50 patients. The results were compared with a control group of 50 patients with the same type of endoprosthesis, but without the porous titanium alloy/HA coating. Both groups of patients were operated on and evaluated by the same orthopedic surgeons with a mean follow up of 11.4 years in the HA group and 10.6 years in the control group. RESULTS: HHS in the control group was preoperatively 35.5 points (range 26-49) and 85.1 points (range 54-100) in the time of the last control. HHS in the HA group was preoperatively 34.1 points (range 27-56) and 94.4 points (range 89-100) in the time of the last control. In 28 cases (56%) of the control group a range of translucencies were obvious. These translucent lines, however, did not appear with any of the patients in the coated implant group except one infection stem migration. CONCLUSION: Experience with the HA-type coated hip implants demonstrates substantially higher degree and quality of osteointegration in the porous titanium alloy/HA type implants.

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