Hintergrund: Wird bei älteren Risikopatient:innen mit Hüft-Totalendoprothese ein Revisionseingriff erforderlich und ist die zementfreie Pfanne noch gut knöchern integriert, besteht die Möglichkeit zur Zementierung einer Dual Mobility Pfanne (DMC) nach Inlay-Entfernung. Neben der postoperativen Prävention einer erneuten Luxation ist ein Vorteil dieser Off-Label-Anwendung einer DMC, dass die alte Pfanne belassen und somit Knochensubstanz erhalten werden kann. Aus dieser Vorgehensweise resultiert auch eine geringere Operations (OP)-Dauer, was gerade für multimorbide Patientengruppen von Bedeutung ist. Fragestellung: Da es bislang nur wenige Untersuchungen zu diesem Verfahren gibt, sollte ermittelt werden, ob die Zementierung einer DMC in eine fest knöchern verankerte Pfanne eine effektive Option für den Revisionseingriff bei Risikopatient:innen darstellt. Methoden: In dieser retrospektive Kohortenstudie wurden 33 Fälle zwischen 2015 und 2020 eingeschlossen. Häufigste Indikationen waren Rezidivluxationen (42 %) und Periprothetische Femurfrakturen (PPF) (39 %). Weitere Indikationen waren Inlay-Verschleiß (9 %), (Pseudo- )Tumor (6 %) und Schaftlockerung (3 %). Das mittlere Patientenalter betrug 79 ± 7 Jahre, die mittlere Nachuntersuchungs (NU)-Zeit 28,5±17,3Monate. Zur NU waren 15Patient:innen verstorben und ein Patient Lost-to-Follow-Up. Die klinische Auswertung erfolgte für 17 und die radiologische Auswertung für 33 Patient:innen. Primärer Endpunkt war die Pfannenrevision aufgrund jedweder Ursache. Sekundärer Endpunkt war die Prothesenlockerung im Röntgenbild. Die Funktion des Hüftgelenks und die Lebensqualität der Patienten wurden als tertiärer Endpunkt zusammengefasst und mit Hilfe des HHS, WOMAC und UCLA erhoben. Ergebnisse: Der mittlere ASA-Score zum Zeitpunkt des Revisionseingriffs betrug 2,8 ± 0,6. Die mittlere OP-Dauer belief sich auf 124 ± 52 min. In zwei Fällen kam es zur Re-Luxation (6 %, Wechsel auf Constrained Liner). Es zeigte sich eine aseptische Lockerung der DMC (3 %) sowie eine Konusschädigung (3 %). Weitere Revisionen waren erforderlich wegen einer PPF (3 %, ORIF) sowie einer Wundheilungsstörung (3 %, Implantat-erhaltende Wundrevision). Die mittleren Punktwerte der einzelnen Scores zur NU lagen bei 59 ± 22 (HHS), 60 ± 26 (WOMAC) und 4 ± 2 (UCLA). Insgesamt ergaben sich nach Auswertung der Röntgenbilder – abgesehen von der erwähnten Revision bei Pfannenausbruch – keine weiteren Anzeichen für Lockerungen oder Veränderungen der DMC-Position, sodass die Überlebensraten nach einer mittleren NU von 28,5 Monaten bei 86,8 % (n = 33) für den primären Endpunkt und bei 92,3 % (n = 22) für den sekundären Endpunkt lag. Schlussfolgerung: Die Off-Label-Zementierung einer DMC in eine fest verankerte Pfanne weist kurz- bis mittelfristig eine geringe Lockerungs- sowie Gesamtkomplikationsrate auf. Ob das Verfahren auch bei längerer Beobachtungszeit gute Ergebnisse zeigt, müssen weitergehende Untersuchungen klären. / Background: If a revision procedure is required in an elderly high-risk patient after a previous total hip arthroplasty and if the cementless acetabular cup is still well integrated in the bone, it is possible to insert a cemented Dual Mobility Cup (DMC) after removal of the inlay. In addition to the postoperative prevention of re-dislocation, this “off-label” application allows the old cup to be left in place. Therefore, bone substance can be preserved. It also usually results in a shorter Operation (OP) time, which is particularly important for this high-risk patient groups. Objective: As there are only few studies on the success of this procedure so far, the aim is to determine whether cementing a DMC into a firmly anchored cup is an effective option for revision surgery in high-risk patients. Methods: This retrospective cohort study included 33 patients between 2015 and 2020. The most common indications were recurrent dislocation (42 %) and periprosthetic fracture (39 %). Other indications were inlay wear (9 %), (pseudo-)tumour (6 %) and socket loosening (3 %). The mean patient age was 79 ± 7 years, and the mean follow-up (FU) time was 28.5 ± 17.3 months. At FU, 15 patients were deceased, and one patient was lost-to-follow-up. Data from 17 patients were available for the clinical evaluation and data from 33 patients for the radiological evaluation. The primary endpoint was revision of the inserted cup due to any cause. The secondary endpoint was prosthesis loosening as determined by the radiograph. The function of the hip joint and the quality of life of the patients were summarized as the tertiary endpoints and assessed using the HHS, WOMAC and UCLA. Results: The mean ASA-score at the time of revision surgery was 2.8 ± 0.6 and the mean operative time was 124 ± 52 min. Re-dislocation occurred in two cases (6.1 %, conversion to a constrained liner). There was one aseptic loosening of the DMC construct (3.0 %) and one case of cone damage (3.0 %). Further revisions were required due to a periprosthetic fracture (3.0 %, open reduction with internal fixation) and a wound healing disorder (3.0 %, implant-preserving wound revision). The mean scores at FU were 59 ± 22 (HHS), 60 ± 26 (WOMAC) and 4 ± 2 (UCLA). Overall, after evaluation of the radiographs, there was no evidence of loosening or change in DMC position, apart from the aforementioned revision for acetabular loosening. Thus, the survival rate after the mean FU of 28.5 months was 86,8 % (n = 33) for the primary endpoint and 92,3 % (n = 22) for the secondary endpoint. Conculsion: The “off-label” cementation of a DMC into a firmly anchored acetabular cup has a low loosening rate and a low overall complication rate in the short to medium term. Whether the procedure also shows good results over a longer observation period must be clarified in further studies.

La dégénérescence articulaire sévère de la hanche est une pathologie fréquente et son traitement ultime est le remplacement prothétique. L’arthroplastie la plus répandue au monde est la prothèse totale de hanche (PTH) avec un couple de frottement métal-sur-polyéthylène (MPE). Cependant ce type d’intervention présente une longévité limitée à cause de l’usure de PE et ne convient pas aux patients actifs souffrant de coxarthrose sévère tôt dans leur vie. Afin de palier à ce problème, une nouvelle génération de surfaces de frottement métal-sur-métal (MM) est actuellement employée. Ces surfaces de frottement sont utilisées en PTH avec tête de 28 mm, en resurfaçage (RH) et avec la PTH à tête de grand diamètre. Alors qu’il y a beaucoup d’évidence à l’égard du bon fonctionnement des implants PTH 28 mm et du RH, les données quant aux performances in vivo des PTH MM à grand diamètre manquent. Malgré cela, ces implants sont utilisés à grande échelle. Dans un premier temps, l’objectif de ce travail de recherche était d’évaluer l’effet et de comparer les taux d’ions chrome (Cr) et cobalt (Co) chez des sujets porteurs de PTH MM à grand diamètre à ceux de 64 porteurs de RH, tous deux possédant des surfaces de frottement aux propriétés tribologiques identiques. Dans un deuxième temps, nous avons comparé les taux ioniques (Cr, Co et titane (Ti)) entre quatre PTH MM à grand diamètre provenant de fabricants différents (Zimmer, DePuy, Smith & Nephew et Biomet). Les mesures d’ions étaient effectuées dans le sang entier dans un laboratoire indépendant par la technique de spectrophotométrie de masse à haute résolution HR-ICP-MS, pour l’ensemble de ce travail de recherche. Les deux comparaisons ont démontré le rôle crucial joué par la modularité au niveau de la jonction tête-col des PTH MM à grand diamètre. En effet, des écarts considérables dans les concentrations ioniques de Co ont été retrouvés entre les RH et PTH Durom ayant un couple de frottement identique, ainsi qu’entre les 4 différents designs de PTH MM à grand diamètre comparés entre eux. La PTH MM à grand diamètre Durom était la moins favorable alors que celle de Biomet était la plus performante. Nos observations démontrent que des sources inattendues comme la jonction tête-col de certains implants PTH MM à grand diamètre peuvent contribuer au relargage ionique systémique. Une meilleure compréhension de ce phénomène est indispensable avant l’utilisation clinque de nouveaux implants de ce type. / The treatment for advanced degenerative hip disease consists in replacing the native joint with artificial implants. This is a very common procedure and the type of arthroplasty most practiced worldwide is metal-on-polyethylene (MOPE) total hip replacement (THR). However, this type of bearing has limited lifespan and is not adapted for active patients struggling with hip osteoarthritis early in their lives. In order to increase implant longevity, new generation, metal-on–metal (MOM) bearing surfaces is used nowadays in this particular population. These MOM bearings are used in 28 mm THR, in resurfacing hip arthroplasty (RH) and in large diameter head THR. Although consistent results have been obtained with the 28 mm THR and RH, large diameter head THR are increasingly used despite lack of scientific data about their performances. The main purpose of our first paper was to compare chromium (Cr) and cobalt (Co) concentrations among patients implanted with large diameter head THR and with RH. In this case, both bearing surfaces presented identical tribological properties. In the second paper, we compared performances in terms of ion release (Cr, Co and titanium (Ti)) from four different manufacturers of large diameter head THR systems (Zimmer, DePuy, Smith & Nephew and Biomet). Whole blood was used for all samples and ion measurements were conducted by an independent laboratory in a blinded fashion, using high-resolution inductive coupled plasma mass spectrophotometry (HR-ICP-MS). Both papers have emphasized the crucial role played by modularity at the head-neck junction in metal ion release from large diameter THR MOM bearings. In fact, significant differences were found in Co ion concentration between large head THR and HRA as well as among the different designs of large head THRs. Briefly, the Durom large head THR system was the least favorable implant while the Biomet large head THR system showed the best results. Our results prove that systemic ion release might origin from surprising sources such as modularity at the head-neck junction in patients implanted with certain large head MOM THR systems. A better comprehension of head-neck junction biomechanics is necessary before clinical use of such new devices.

INTRODUÇÃO: O diagnóstico microbiológico das infecções em artroplastias é de fundamental importância para a definição da estratégia de uso dos antimicrobianos. As culturas microbiológicas convencionais apresentam elevados índices de falso-negativos, em especial, nas infecções crônicas, em que é frequente a presença do biofilme aderido ao implante. A utilização de amostras deste biofilme, viáveis à cultura, a partir de seu descolamento do implante pela técnica de sonicação, tem mostrado aumento da sensibilidade em publicações recentes. O objetivo deste estudo foi comparar os resultados das culturas microbiológicas de fragmentos de tecido periprotético, realizadas em meio sólido, àquelas obtidas pelo cultivo do líquido oriundo da sonicação do implante removido, semeado, inicialmente, em frascos de hemocultura e, posteriormente, em meio sólido. MÉTODOS: Neste estudo de análise descritiva, prospectivo e comparativo, 30 pacientes com diagnóstico de infecção em artroplastias de joelho ou quadril, com mais de 90 dias de história, tiveram seus implantes cirurgicamente removidos e foram coletadas seis amostras do tecido periprotético, de locais previamente determinados, para a realização de cultura microbiológica em meios sólidos. Simultaneamente, os implantes foram submetidos ao processo de sonicação e o material resultante foi injetado em frascos de hemocultura BD Bactec e submetidos ao processo de cultura automatizada. Todas as amostras foram pesquisadas quanto à presença de bactérias aeróbias, anaeróbias, micobactérias e fungos, e os resultados comparados por meio de análise estatística, em busca da superioridade de um método sobre o outro. Como objetivo secundário, buscou-se analisar quais os pontos de coleta do tecido periprotético teriam maior sensibilidade em suas culturas. RESULTADOS: Não houve diferenças estatisticamente significantes da amostra em relação ao gênero, patologia articular primária, tipo de artroplastia, localização do implante ou lateralidade. Em 17 casos (56,7%), houve uso de antimicrobianos no período de 15 dias que antecederam a retirada do implante. O método de cultura do fluido de sonicação mostrou sensibilidade de 86,7% e foi superior, de modo estatisticamente significante (P < 0,001), em relação à cultura dos fragmentos periprotéticos, cujos resultados tiveram sensibilidades entre 26,7 e 53,3%. O uso de antibioticoterapia recente não interferiu de modo estatisticamente significante na sensibilidade da cultura do líquido oriundo da sonicação. (P = 0,113). Quanto ao objetivo secundário, a coleta de fragmentos da membrana periprotética mostrou maior sensibilidade, estatisticamente significante, na comparação com três dos demais cinco pontos de coleta (P < 0,05). CONCLUSÕES: A cultura microbiológica do líquido obtido por sonicação dos implantes removidos de pacientes com diagnóstico de infecção periprotética e semeado inicialmente em frascos de hemocultura mostrou ter sensibilidade superior, estatisticamente significante, à cultura convencional de fragmentos do tecido periprotético semeados em meios sólidos. A cultura microbiológica da membrana periprotética mostrou ter maior sensibilidade em relação à maioria dos outros sítios que tiveram fragmentos de tecido periprotético pesquisados. / INTRODUCTION: Microbiological diagnosis in periprosthetic infection is of fundamental importance to define the most appropriate antimicrobial strategies. Conventional microbiological cultures have high rates of false negatives, especially in chronic infections, in which there is often the presence of biofilm attached to the implant. The use of samples of viable culturable biofilm taken from the detachment of the implant by sonication technique has been shown to increase the sensitivity in recent studies. The objective of this study was to compare the results of microbiological cultures of periprosthetic tissue fragments, made in a solid medium, to those obtained through the cultivation of the liquid coming from the sonication of the removed implant initially seeded in blood culture bottles and later in solid medium. METHODS: Using descriptive, prospective and comparative analysis, thirty patients with a diagnosis of infected knee or hip arthroplasty, with more than ninety days of history, had their implants surgically removed. Six periprosthetic tissue samples, collected at predetermined places, were used for microbiological culture on solid media. Simultaneously, the implants were subjected to the sonication process, and the resulting material was injected into vials of BD Bactec blood cultures and subjected to an automated culture process. All samples were screened for the presence of aerobic bacteria, anaerobes, mycobacteria and fungi and the results compared by statistical analysis to find the superiority of one method over the other. As a secondary objective, this study sought to analyze which of the periprosthetic tissue collecting points would have greater sensitivity in their cultures. RESULTS: There were no statistically significant differences in the sample as related to gender, primary joint pathology, type of arthroplasty, implant location or laterality. In seventeen cases (56.7%), antimicrobials were used within the 15-day period leading up to the removal of the implant. The sonication culture fluid showed a sensitivity of 86.7% and was higher, statistically significant (P < 0.001) in relation to the culture of periprosthetic fragments, where results displayed sensitivities between 26.7 and 53.3%. The use of recent antibiotic therapy did not affect the sensitivity of the liquid coming from the sonication culture, which was not statistically significant (P = 0.113). As for the secondary objective, the collection of periprosthetic membrane fragments showed higher sensitivity, statistically significant (P < 0.05), as compared to three of the remaining five collecting points. CONCLUSIONS: The microbiological culture liquid obtained by sonication of the implants removed from patients with diagnosis of periprosthetic infection and initially seeded in blood culture bottles was shown to have superior sensitivity, statistically significancy, as compared to conventional culture of the periprosthetic tissue fragments seeded on solid media. The microbiological culture of the periprosthetic membrane seems to be more sensitive compared to most other sites that had periprosthetic tissue fragments surveyed

La révision d’arthroplastie de la hanche en cas d’important déficit osseux acétabulaire peut être difficile. Les reconstructions avec cupule de très grand diamètre ou cupule « jumbo » (≥ 62 mm chez la femme et ≥ 66 mm chez l’homme) sont une option thérapeutique. Nous voulions évaluer la préservation et la restauration du centre de rotation de la hanche reconstruite en la comparant au coté controlatéral sain ou selon les critères de Pierchon et al. Nous voulions également évaluer la stabilité du montage à un suivi d’au moins 2 ans. Il s’agissait de 53 cas consécutifs de révision acétabulaire pour descellement non septique avec implantation d’une cupule jumbo sans ciment à l’Hôpital Maisonneuve-Rosemont. Le déficit osseux évalué selon la classification de Paprosky et al. Les cupules implantées avaient un diamètre moyen de 66 mm (62-81) chez les femmes et 68 mm (66-75) chez les hommes. L’allogreffe osseuse morcelée et massive était utilisée dans 34 et dans 14 cas respectivement. La cupule a été positionnée avec un angle d’inclinaison moyen de 41.3° (26.0-53.0). Le centre de rotation de la hanche reconstruite a été jugé satisfaisant dans 78% de cas sur l'axe médiolatéral, 71% sur l'axe craniopodal et amélioré dans 27% dans cet axe. Au recul moyen radiologique de 84.0 mois (24.0-236.4) et clinique de 91.8 mois (24.0 – 241.8): 6 cas étaient décédés, 3 perdus au suivi. On a observé le descellement radiologique dans un 1 cas, la luxation récidivante dans 5 cas et l’infection dans 4 cas. Le retrait de la cupule a été effectué dans 2 cas pour infection. L’ostéointégration des greffons osseux était complète dans tous les cas sauf 3. Les scores cliniques étaient pour le HHS de 82 +/-17, le WOMAC de 86 +/- 14 et le SF-12 physique de 46 +/- 12 et mental 53 +/-13. La cupule jumbo peut être considérée comme un moyen fiable pour gérer le déficit osseux dans les révisions acétabulaires. Elle permet de conserver ou d’améliorer la position du centre de rotation physiologique de la hanche. La fixation sans ciment favorise l’ostéointégration de la cupule et permet une stabilité à moyen terme. Le taux de complications est comparable ou inférieur à d'autres procédures de reconstruction. / Acetabular implant revision with large bone defects, can be challenging. One of the reconstruction options is a large outer diameter cup or “jumbo cup” (≥62 mm in women and ≥66 mm in men). We hypothesized that cementless jumbo cups is a reliable technique to preserve or reconstruct hip center of rotation. We also evaluated stability at least 2 two years follow up. Fifty-three consecutive non septic loosening acetabular arthroplasty revisions at Hopital Maisonneuve-Rosemont where a cementless jumbo cup was used were assessed. Bone defect was evaluated according to Paprosky classification. Mean implanted component size was 66 mm (62-81) in women and 68 mm (66-75) in men. Cancelous bone chips allograft was used in 34 cases and bulk bone allograft in 14. Immediate postoperative AP view showed a mean abduction cup angle of 41.3° (26.0-53.0). Hip centre were found at satisfy position in 78% on mediolateral axis, in 71% on craniopodal axis and it was improved in 27% in this late axis. At the mean follow up of 84.0 months (24.0-236.4) radiologically and 91.8 months (24.0-241.8) clinically: 6 patients were died and 3 were lost of follow up. Complications were: dislocation in 5 cases (4 revisions with constrained liner), infection in 4 cases (2 treated conservatively and 2 revised in 2 times procedure) and radiographic loosening in 1 case. Bone graft integration was completed in all except in 3 cases. Clinically, the mean HHS was 82% +/- 17, WOMAC 86 +/- 14, physical SF-12 46 +/- 12 and mentally SF-12 53 +/- 13. Jumbo cups appear as a reliable procedure to manage bone loss in acetabular revision. It allows conservation or improvement of physiologic hip center. Also, cementless fixation promote bone integration. with subsequent cup stabilitity. The complication rate is comparable or may be less than others reconstruction procedures .

This project attempts to quantify the integrity of the fixation of total hip arthro- T plasties (THAs) by observing vibration signal features. The aim of this thesis is, therefore, to find the signal differences between firm and loose prosthesis. These difference will be expressed in different transformed domains with the expectation that a certain domain will provide superior results. Once the signal differences have been determined they will be examined for their ability to quantify the looseness. Initially, a new definition of progressive, femoral component loosening was created, based on the application of mechanical fit, involving four general conditions. In order of increasing looseness the conditions (with their equivalent engineering associations) are listed as, firm (adherence), firm (interference), micro-loose (transition) and macro-loose (clearance). These conditions were then used to aid in the development and evaluation of a simple mathematical model based on an ordinary differential equation. Several possible parameters well suited to quantification such as gap displacement, cement/interface stiffness and apparent mass were the identified from the model. In addition, the development of this model provided a solution to the problem of unifying early and late loosening mentioned in the literature by Li et al. in 1995 and 1996. This unification permitted early (micro loose) and late (macro loose) loosening to be quantified, if necessary, with the same parameter. The quantification problem was posed as a detection problem by utilising a varying amplitude input. A set of detection techniques were developed to detect the quantity of a critical value, in this case a force. The detection techniques include deviation measures of the instantaneous frequency of the impulse response of the system (accuracy of 100%), linearity of the systems response to Gaussian input (total accuracy of 97.9% over all realisations) and observed resonant frequency linearity with respect to displacement magnitude (accuracy of 100%). Note, that as these techniques were developed with the model in mind their simulated performance was, therefore, considerably high. This critical value found by the detector was then fed into the model and a quantified output was calculated. The quantification techniques using the critical value approach include, ramped amplitude input resonant analysis (experimental accuracy of 94%) and ramped amplitude input stochastic analysis (experimental accuracy of 90%). These techniques were based on analysing the response of the system in the time-frequency domain and with respect to its short-time statistical moments to a ramping amplitude input force, respectively. In addition, other mechanically sound forms of analysis, were then applied to the output of the nonlinear model with the aim of quantifying the looseness or the integrity of fixation of the THA. The cement/interface stiffness and apparent mass techniques, inspired by the work of Chung et.al. in 1979, attempt to assess the integrity of fixation of the THA by tracking the mechanical behaviour of the components of the THA, using the frequency and magnitude of the raw transducer data. This technique has been developed fron the theory of Chung etal but with a differing perspective and provides accuracies of 82% in experimentation and 71% in simulation for the apparent mass and interface stiffness techniques, respectively. Theses techniques do not quantify all forms of clinical loosening, as clinical loosening can exist in many different forms, but they do quantify mechanical loosening or the mechanical functionality of the femoral component through related parameters that observe reduction in mechanical mass, stiffness and the amount of rattle generated by a select ghap betweent he bone/cement or prosthesis/cement interface. This form of mechanical loosening in currently extremely difficult to detect using radiographs. It is envisaged that a vibration test be used in conjunction with radiographs to provide a more complete picture of the integrity of fixation of the THA.

INTRODUÇÃO: O diagnóstico microbiológico das infecções em artroplastias é de fundamental importância para a definição da estratégia de uso dos antimicrobianos. As culturas microbiológicas convencionais apresentam elevados índices de falso-negativos, em especial, nas infecções crônicas, em que é frequente a presença do biofilme aderido ao implante. A utilização de amostras deste biofilme, viáveis à cultura, a partir de seu descolamento do implante pela técnica de sonicação, tem mostrado aumento da sensibilidade em publicações recentes. O objetivo deste estudo foi comparar os resultados das culturas microbiológicas de fragmentos de tecido periprotético, realizadas em meio sólido, àquelas obtidas pelo cultivo do líquido oriundo da sonicação do implante removido, semeado, inicialmente, em frascos de hemocultura e, posteriormente, em meio sólido. MÉTODOS: Neste estudo de análise descritiva, prospectivo e comparativo, 30 pacientes com diagnóstico de infecção em artroplastias de joelho ou quadril, com mais de 90 dias de história, tiveram seus implantes cirurgicamente removidos e foram coletadas seis amostras do tecido periprotético, de locais previamente determinados, para a realização de cultura microbiológica em meios sólidos. Simultaneamente, os implantes foram submetidos ao processo de sonicação e o material resultante foi injetado em frascos de hemocultura BD Bactec e submetidos ao processo de cultura automatizada. Todas as amostras foram pesquisadas quanto à presença de bactérias aeróbias, anaeróbias, micobactérias e fungos, e os resultados comparados por meio de análise estatística, em busca da superioridade de um método sobre o outro. Como objetivo secundário, buscou-se analisar quais os pontos de coleta do tecido periprotético teriam maior sensibilidade em suas culturas. RESULTADOS: Não houve diferenças estatisticamente significantes da amostra em relação ao gênero, patologia articular primária, tipo de artroplastia, localização do implante ou lateralidade. Em 17 casos (56,7%), houve uso de antimicrobianos no período de 15 dias que antecederam a retirada do implante. O método de cultura do fluido de sonicação mostrou sensibilidade de 86,7% e foi superior, de modo estatisticamente significante (P < 0,001), em relação à cultura dos fragmentos periprotéticos, cujos resultados tiveram sensibilidades entre 26,7 e 53,3%. O uso de antibioticoterapia recente não interferiu de modo estatisticamente significante na sensibilidade da cultura do líquido oriundo da sonicação. (P = 0,113). Quanto ao objetivo secundário, a coleta de fragmentos da membrana periprotética mostrou maior sensibilidade, estatisticamente significante, na comparação com três dos demais cinco pontos de coleta (P < 0,05). CONCLUSÕES: A cultura microbiológica do líquido obtido por sonicação dos implantes removidos de pacientes com diagnóstico de infecção periprotética e semeado inicialmente em frascos de hemocultura mostrou ter sensibilidade superior, estatisticamente significante, à cultura convencional de fragmentos do tecido periprotético semeados em meios sólidos. A cultura microbiológica da membrana periprotética mostrou ter maior sensibilidade em relação à maioria dos outros sítios que tiveram fragmentos de tecido periprotético pesquisados. / INTRODUCTION: Microbiological diagnosis in periprosthetic infection is of fundamental importance to define the most appropriate antimicrobial strategies. Conventional microbiological cultures have high rates of false negatives, especially in chronic infections, in which there is often the presence of biofilm attached to the implant. The use of samples of viable culturable biofilm taken from the detachment of the implant by sonication technique has been shown to increase the sensitivity in recent studies. The objective of this study was to compare the results of microbiological cultures of periprosthetic tissue fragments, made in a solid medium, to those obtained through the cultivation of the liquid coming from the sonication of the removed implant initially seeded in blood culture bottles and later in solid medium. METHODS: Using descriptive, prospective and comparative analysis, thirty patients with a diagnosis of infected knee or hip arthroplasty, with more than ninety days of history, had their implants surgically removed. Six periprosthetic tissue samples, collected at predetermined places, were used for microbiological culture on solid media. Simultaneously, the implants were subjected to the sonication process, and the resulting material was injected into vials of BD Bactec blood cultures and subjected to an automated culture process. All samples were screened for the presence of aerobic bacteria, anaerobes, mycobacteria and fungi and the results compared by statistical analysis to find the superiority of one method over the other. As a secondary objective, this study sought to analyze which of the periprosthetic tissue collecting points would have greater sensitivity in their cultures. RESULTS: There were no statistically significant differences in the sample as related to gender, primary joint pathology, type of arthroplasty, implant location or laterality. In seventeen cases (56.7%), antimicrobials were used within the 15-day period leading up to the removal of the implant. The sonication culture fluid showed a sensitivity of 86.7% and was higher, statistically significant (P < 0.001) in relation to the culture of periprosthetic fragments, where results displayed sensitivities between 26.7 and 53.3%. The use of recent antibiotic therapy did not affect the sensitivity of the liquid coming from the sonication culture, which was not statistically significant (P = 0.113). As for the secondary objective, the collection of periprosthetic membrane fragments showed higher sensitivity, statistically significant (P < 0.05), as compared to three of the remaining five collecting points. CONCLUSIONS: The microbiological culture liquid obtained by sonication of the implants removed from patients with diagnosis of periprosthetic infection and initially seeded in blood culture bottles was shown to have superior sensitivity, statistically significancy, as compared to conventional culture of the periprosthetic tissue fragments seeded on solid media. The microbiological culture of the periprosthetic membrane seems to be more sensitive compared to most other sites that had periprosthetic tissue fragments surveyed

Submitted by Simone Souza (simonecgsouza@hotmail.com) on 2017-09-20T14:37:32Z No. of bitstreams: 1 DISS_2014_Miguel Aprelino Alito.pdf: 4695957 bytes, checksum: 0f8d53c15612c14ec0bd4276f60d6c20 (MD5) / Approved for entry into archive by Jordan (jordanbiblio@gmail.com) on 2017-09-26T12:50:06Z (GMT) No. of bitstreams: 1 DISS_2014_Miguel Aprelino Alito.pdf: 4695957 bytes, checksum: 0f8d53c15612c14ec0bd4276f60d6c20 (MD5) / Made available in DSpace on 2017-09-26T12:50:06Z (GMT). No. of bitstreams: 1 DISS_2014_Miguel Aprelino Alito.pdf: 4695957 bytes, checksum: 0f8d53c15612c14ec0bd4276f60d6c20 (MD5) Previous issue date: 2014-08-25 / Introdução: Protocolos multimodais, quando empregados, melhoram variáveis clínicas perioperatórias e pós-operatórias. Existe pouca informação sobre abreviação do jejum préoperatório com oferta de líquidos claros enriquecidos com carboidratos e imunomoduladores em operações ortopédicas. O projeto ACERTO (ACEleração da Recuperação Total pósoperatória) é baseado em um programa europeu já existente (ERAS) e fundamentado no paradigma da medicina baseada em evidências. É antes de tudo um programa educativo. Objetivos: Avaliar variáveis clínicas, bioquímicas inflamatórias e segurança de um protocolo multimodal em pacientes submetidos à cirurgia de artroplastia total do quadril, utilizando-se técnica cimentada em fêmur e sem cimento no acetábulo (artroplastia total de quadril tipo híbrida). Métodos: Estudo prospectivo com 32 pacientes (16 do sexo masculino, com idade média de 58 anos variando de 26 a 85 anos) randomizados em dois grupos: 17 pacientes (Grupo ACERTO) submetidos a jejum abreviado com oferta de maltodextrina a 12,5%, 2h antes da indução anestésica e uso de dieta imunomoduladora por cinco dias previamente a cirurgia; 15 pacientes (Grupo CONTROLE) submetidos a jejum de 8 horas sem terapia nutricional préoperatória. Foram avaliados clinicamente broncoaspiração na indução anestésica e tempo de internação e em exames laboratoriais os níveis de hemoglobina (HB), velocidade de hemossedimentação (VHS) e proteína C reativa (PCR) no pré-operatório e com 48h de pósoperatório. Resultados: Não ocorreram óbitos, infecções, luxações da prótese, necessidade de reoperação, ou transfusões sanguíneas. Nenhum caso de broncoaspiração ocorreu na indução anestésica. Pacientes do Grupo ACERTO apresentaram, em média, dois dias a menos de internação hospitalar (P < 0,01). A taxa de HB foi similar entre os grupos no pré e pósoperatório. Valores de VHS se mantiveram semelhantes entre os grupos no pós-operatório (p = 0,09), mas a PCR foi maior no grupo CONTROLE no pós-operatório (p = 0,01). Conclusão: Abreviação do jejum pré-operatório com oferta de carboidratos na artroplastia total de quadril é segura, podendo ser praticada. O protocolo investigado como um todo diminuiu o tempo de internação hospitalar e valores de PCR no pós-operatório. / Introduction: Multimodal protocols, when used, enhance several perioperative clinical variables. Limited information is available about the reduction of preoperative fasting with administration of clear liquids enriched with carbohydrate and immunomodulators in orthopedic surgeries. The ACERTO (Accelerated Postoperative Total Recovery) is based on an existing European program (ERAS) and based on the paradigm of evidence-based medicine. It is an educational program. Objectives: To evaluate clinical, biochemical inflammatory variables and safety of the method, shortening up the fast with drink containing carbohydrates and use of immunomodulatory diet in patients undergoing surgery for total hip arthroplasty using cementless technique on the femur and the acetabulum without cement (total hip arthroplasty hybrid type). Methods: A prospective study of 32 patients (16 males, with a mean age of 58 years ranging de 26 to 85 years) were randomized into two groups: 17 patients (Group ACERTO) undergoing abbreviated to offer 12,5% maltodextrin fasting, 2h before induction of anesthesia and use of immunomodulatory diet for five days prior to surgery; 15 patients (Group CONTROL) fasted for 8 hours without preoperative nutritional therapy. Clinically aspiration during induction of anesthesia and hospitalization time and in laboratory tests the levels of hemoglobin (Hb), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) preoperatively and 48 hours postoperatively were evaluated. Results: There were no deaths, infections, dislocations of the prosthesis, reoperation, or blood transfusions. No cases of aspiration occurred during anesthetic induction. Group ACERTO patients had, on average, two days less hospitalization (P < 0,01). Results of hemoglobin did not differ among groups in preoperative and postoperative. VHS values remained similar between groups postoperatively (p = 0,09), but CRP was higher in the control group postoperatively (p = 0,01). Conclusion: Preoperative fasting abbreviation with of carbohydrates in total hip arthroplasty is safe and may be practiced. The protocol investigated as a whole, decreased hospital stay and CRP levels postoperatively.