**11. References**

406 Recent Advances in Arthroplasty

Despite of being osteoconductive, the HA is not osteoinductive: in order to achieve a satisfying bone ingrowth, further factors could be added, such as multipotential stromal stem cells or PRP growth factors (Boyde et al., 1999), in order to favour and accelerate bone regeneration. Nowadays, combination of mature stromal cells and HA-based scaffolds represent an useful tissue regeneration approach to be used in a clinical setting: unfortunately, only few papers describe the clinical use of massive graft made of HA-based scaffolds (Marcacci et al., 2007) and long-term comparative studies are needed to evaluate

**Material Osteoconduction Osteoinduction Osteogenesis Notes** 

\ +++ +

plasma (PRP) \ ++ ++ Large availability.

(HA) ++ \ \ Immediate structural

Table 5. Different materials available as bone substitutes and their respective biologic

depends on dimension and characteristics of bone defect but are also patient-related.

As the incidence of primary and revision total knee arthroplasty will continue to increase, proper management of femoral and tibial bone loss represents a common situation that have to be faced by the orthopedic surgeon. The choice between different surgical options

Whatever technique is used in the management of bone loss during knee arthroplasty, certain fundamentals must be applied and the remaining bone structure will guide treatment. For treatment of any periarticular defect requiring more than a minimal

Structural +++ \ \ Fresh frozen allografts

++ + \ High cost

+++ +++ +++ Good perspective in the

dried ones. Morcelised + \ \

Gold standard: all elements for bone regeneration

show better mechanical properties than freeze-

Potentially limited availability. Scaffold is needed

Scaffold is needed

support

future

Bone autograft +++ ++ ++

their clinical effectiveness (Table 5).

Bone allograft

Bone morphogenetic proteins (BMPs)

Platelet-rich

Demineralized bone matrix (DBM)

Hydroxyapatite

Composite grafts: BMPs+HA

properties.

**9. Conclusions** 


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**Part 4** 

**Infection** 


**Part 4** 

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**Infection** 

**19** 

*Australia* 

**Infection in Primary Hip and Knee Arthroplasty** 

*University of Melbourne, Department of Surgery, St. Vincent's Hospital Melbourne* 

Since the advent of prosthetic joint replacement, patients suffering from bone and joint pathology have benefited from significant improvements in mobility and pain relief. In Australia 39,200 hip replacements and 39,500 knee replacements were performed in 2009 (Australian Orthopaedic Association National Joint Replacement Registry [AOA NJRR]) (Graves, et al. 2010). With an ageing population, the number of patients undergoing these procedures is projected to increase significantly over time. Data from the United States of America predicts that by 2030, the number of patients undergoing primary hip and knee replacement will increase by 174% and 673% respectively (Kurtz, et al. 2007). The major complication of such techniques is infection of the prosthetic device, which is associated with significant costs to individual patients and to the public health system. Significant morbidity is associated with prosthetic joint infections including the need for further operative procedures, long-term antibiotic therapy, and prolonged hospitalisation. Thereafter, the mortality rate from prosthetic joint infection is estimated to be between 1.0 to 2.7 precent (Ahnfelt, et al. 1990, Zimmerli 2006, Zimmerli, et al. 2004). Aside from the effects on the individual patient, the financial cost to the health system is considerable. The estimated hospital costs is \$ 96 166 (US) per patient requiring revision arthroplasty for

infection, which is 4.8 times the cost of a primary arthroplasty(Bozic & Ries 2005).

This chapter examines the underlying epidemiology, diagnosis, treatment and challenges in

Identification of prosthetic joint infection currently relies on diagnostic criteria, which include: histopathologic evidence of acute inflammation of periprosthetic tissue, presence of a sinus tract, macroscopic purulence surrounding the prosthesis observed intraoperatively or two or more positive microbiological cultures with the same organism isolated from the prosthetic joint fluid or tissue(Berbari, et al. 1998). We report a rate of prosthetic joint infection between 1.0 – 2.0% in primary lower limb arthroplasty and this is congruent with current literature (Dowsey & Choong 2008, 2009, Swan, et al. 2011). In the United States the rate of infection in knee and hip arthroplasty was 0.92% and 0.88% respectively in a recent review of Medicare data. (Kurtz, et al. 2008). The majority of arthroplasty infections occur in

**1. Introduction** 

managing this problem.

**2. Epidemiology** 

**2.1 Incidence** 

Michelle M. Dowsey, Trisha N. Peel and Peter F.M. Choong

*Department of Orthopaedics, St. Vincent's Hospital Melbourne* 
