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The economic burden of periprosthetic infections is enormous, but the number of economic studies dealing with this issue is very scarce. This review tries to know the economic literature existing, assess the value of current data, and recognize the less costly and more effective procedures for prevention, diagnosis and treatment of periprosthetic infections. Forty five studies meeting the inclusion criteria and adhering to the quality criteria used were carefully analyzed to extract the economic data of relevance in evaluating the magnitude of problem and the more cost-effective solutions. However, because the heterogeneity and the low-quality of most of these studies meta-analytical technique has not been possible. Instead, the studies have been reviewed descriptively. Optimizing the antibiotic use in the prevention and treatment of periprosthetic infection, combined with systemic and behavioral changes in the operating room; detecting and treating the high-risk groups; a quick, simple, reliable, safe, and cost-effective diagnosis, and the rationale management of the instituted infection, specifically using the different procedures according to each particular case, could allow to improve outcomes and produce the highest quality of life for patients and the lowest economic impact. Nevertheless, the cost effectiveness of different interventions to prevent and to treat the periprosthetic infection remains unclear.

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This review summarizes the existing economic literature, assesses the value of current data, and presents procedures that are the less costly and more effective options for the treatment of periprosthetic infections of knee and hip. Optimizing antibiotic use in the prevention and treatment of periprosthetic infection, combined with systemic and behavioral changes in the operating room, the detection and treatment of high-risk patient groups, as well as the rational management of the existing infection by using the different procedures according to each particular case, could allow for improved outcomes and lead to the highest quality of life for patients and the lowest economic impact. Nevertheless, the cost-effectiveness of different interventions to treat periprosthetic infections remains unclear.

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BACKGROUND: Conversion of hip arthrodesis to a THA reportedly provides a reasonable solution, improving function, reducing back and knee pain, and slowing degeneration of neighboring joints associated with a hip fusion. Patients generally are satisfied with conversion despite the fact that range of mobility, muscle strength, leg-length discrepancy (LLD), persistence of limp, and need for assistive walking aids generally are worse than those for conventional primary THA. QUESTIONS/PURPOSES: We compared THA after hip arthrodesis and primary THA to determine whether these procedures would be associated with similar functional scores, maintenance of scores with time, complications and failures, survivorship of the arthroplasty, and patient satisfaction. PATIENTS AND METHODS: We retrospectively matched 48 patients undergoing conversion of a fused hip to a THA between January 1980 and January 2000, with 50 patients receiving a primary THA during the same period. We prospectively followed all patients between January 2000 and January 2010. The changes in function and pain after THA were compared between the two cohorts using the Harris hip score (HHS) and the Rosser Index Matrix (RIM). The Oxford hip score (OHS) and the SF-36 also were used to assess quality of life (QOL) during followup. Complications were collected and survivorship of the THA was evaluated. Patient satisfaction was assessed using the Robertsson and Dunbar questionnaire. The minimum followup was 10 years (mean, 17 years; range, 10-29 years). RESULTS: At last followup, hip function and health-related QOL were similar for patients having conversion of hip arthrodesis to THA and for patients having a routine THA. Scores diminished overall in the two groups between 2000 and 2010, but without a difference for the HHS, RIM QOL, and OHS in the study cohort. The rate of complications, THA survival, and patient satisfaction were similar in both groups. CONCLUSIONS: Conversion of hip arthrodesis to a THA provides substantial improvement of hip function and health-related QOL, with an acceptable rate of complications, good expectancy of survival for the arthroplasty, and high level of patient satisfaction comparable to those of primary THA. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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BACKGROUND: Our working hypothesis was that minimally invasive surgery was superior to conventional surgery for total hip arthroplasty procedure. We compared THR results in the minimally invasive posterior approach with THR results in the conventional posterior approach. METHODS: Prospective, randomised trial. Fifty patients were selected and then divided into two groups based on treatment (minimally invasive posterior approach or conventional posterior approach). DATA COLLECTED: Perioperative bleeding, postoperative pain, time of recovery, component orientation, complications and functional results. One year follow-up. RESULTS: No differences were found in blood loss, surgical time, component orientation, rate of complications or functional result. The minimally invasive lateral approach produced less postoperative pain and a faster recovery, with a shorter hospital stay and earlier walking-start, and a positive economic impact with 5% of the total process cost saved. CONCLUSIONS: Minimally invasive surgery permits less postoperative pain, faster recovery and a positive economic saving, without differences in the rest of the items studied.

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UNLABELLED: Different bearing surfaces, including alumina-on-alumina, have been used to avoid osteolysis. We prospectively followed 288 patients (319 hips) in which an alumina-on-alumina cup was used with a hydroxyapatite stem. The patients' mean age was 52.7 (range, 14-70 years), and the minimum followup was 3 years (mean, 4.7 years; range, 3-8 years). At final followup, five cups (including one with an alumina liner fracture) and two stems underwent revision. The cumulative probability of not having a revision of one or both components for any cause was 97% (95% confidence interval, 94.7%-99.1%). No patient spontaneously reported any noises from the hip and none reported noises when specifically questioned. All patients who had not undergone revision had good clinical results, but five of these patients had radiographic cup loosening at last followup. These data suggest alumina-on-alumina prostheses had reasonable outcomes after 5 years. One acetabular component fractured from trauma. We observed no linear femoral head penetration. Continued followup will be required to determine if reduction in wear between the alumina-on-alumina bearings results in less osteolysis and loosening. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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OBJECTIVE: To determine whether a biphasic calcium phosphate (BCP) ceramic supplemented with fresh autologous bone marrow (BMA) can give rise to adequate bone to achieve a vertebral fusion mass. MATERIALS AND METHODS: A prospective nonrandomized, radiographic study on 35 patients with posterolateral fusion using rigid transpedicular instrumentation for degenerative lumbar disease. At least 2-year follow-up. On the left side: autologous bone graft obtained from decompression. On the right side: a mixture of BCP and fresh autogenous bone marrow from the right iliac crest. Single-level fusion in 22 patients and two or more levels in 13. Patients assessed with x-rays and computed tomography by an orthopedic surgeon and an independent radiologist. Fusion mass was considered "good" when there was a continuous block of bone without radiolucent areas. No intersegmental bony bridging fusion was considered "poor" mass. McNemar, Fisher, and kappa tests were used for statistical analysis. RESULTS: The interobserver agreement (kappa) had an average of 0.75 for the fusion masses. The interobserver average in the radiologic evaluation of ceramic resorption was 0.68. No differences between smokers and nonsmokers were found. Plain radiography findings: good left fusion masses (autologous bone) in 31 patients and poor in 4; good right masses (BMA plus BCP) in 31 patients and poor in 4 (P > 0.05). Computed tomography evaluation: good left fusion masses in 28 patients and poor in 7; good right fusion masses in 31 patients and poor in 4 (P > 0.05). One patient was reoperated, allowing biopsies to be performed: compact bone tissue was observed around hydroxyapatite in the right fusion mass. CONCLUSIONS: The differences detected between right-side and left-side masses are not statistically significant. This indicates that, BMA and BCP, when mixed, behave like composite grafts and are able to generate sufficient bone mass for arthrodesis when a rigid instrumentation is used. However, a larger number of cases and longer follow-up are needed to generalize the indication.

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Hypothetically, hydroxyapatite-coated anatomic-shaped femoral stems and hemispheric acetabular cups should improve biologic fixation of the implant and strength transmission to the bone, improving unsatisfactory results of the first cementless hip prosthesis focused on the stress-shielding phenomenon at the femur and failure of the threaded acetabular cups. A consecutive series of 312 patients who had primary Anatomique Benoist Giraud hip prostheses unilaterally implanted were followed up. We analyzed the clinical and radiographic results and report the outcomes 7-10 years after implantation. Two hundred thirty-two patients were assessed at 7-10 years. The survival rate for the implant was 96.8%; 77.2% of patients had no pain, 72.4% maintained total mobility, and 62.9% were able to walk without restrictions. However, radiologic assessment shows that problems improved but did not disappear. More than 55% of femurs had signs of proximal stress-shielding develop. More important, substantial polyethylene wear was observed in at least 62% of the acetabular inserts at 7-10 years followup.

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Surgical field illumination and visualization is the key for total hip arthroplasty through a mini-incision approach. An easy, quick, and inexpensive method is described, using a conventional endoscopic light-source temporally fixed to conventional hip surgery retractors.

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