Periprosthetic joint infection (PJI) is one of the devastating complications after primary total knee arthroplasty (TKA), which increases the financial burden on patients and affects their quality of life as well. 1-4) Despite modern modalities for preventing infection, the incidence of PJI is 1%-2% after knee replacement surgery. 5,6) As the burden of the lower limb arthroplasty procedure is frequently increasing in the elderly population, the economic burden of PJI is steadily increasing as well. 7) The actual cost of treating patients with PJI is difficult to determine because it depends on multiple factors such as the specific type of treatment given to a patient, bacteria-specific antibiotics, and patient's comorbidities. The spectrum of economic burden comprises inpatient cost as well as outpatient cost, which includes costs for follow-up visits, rehabilitation, and medication. PJI is a dilemma especially in developing countries such as Pakistan. According to the World Bank's classification, Pakistan belongs to the lower-middle-income group. 8) The management of PJI varies from an extended course of antibiotics to surgical debridement, which places massive

Backgroud Due to extensive fibrosis during revision surgery, adequate exposure is essential and it can be achieved with several extensile approach options, such as tibial tubercle osteotomy. Information regarding surgical exposure during revision arthroplasty is limited in developing countries, such as Pakistan, due to the lack of adequate data collection and follow-up. Therefore, the purpose of this study was to evaluate the impact of tibial tubercle osteotomy on final outcome of revision total knee arthroplasty (TKA). Methods A total of 231 revision TKAs were performed between January 2008 and December 2017. Twenty-nine patients underwent tibial tubercle osteotomy for adequate exposure during revision surgery. Of these, 27 patients with complete follow-up were included in our study. Factors examined include age at the time of revision surgery, gender, comorbidities, arthroplasty site (right or left), body mass index (BMI), and primary indications for the tibial tubercle osteotomy during revision TKA. Functional outcome was measured by using Knee Society score (KSS) at 3 months and the final follow-up. All statistical analysis was done using SPSS version 20.0 with a p -value < 0.05 considered significant. Results Out of 27 patients, 6 patients (22.2%) were men and 21 patients (77.7%) were women. Right knee revision arthroplasty was performed in 15 patients (55.5%), left knee revision arthroplasty was performed in 12 patients (44.4%), and bilateral revision surgery was performed in only 1 patient (3.7%). The mean BMI was 29.2 kg/m 2 . We used a constrained condylar knee in 20 patients (74%), a rotating hinge knee in 5 patients (18.5%), and mobile bearing tray plus metaphyseal sleeves in 2 patients (7.4%). The KSS was 52.21 ± 4.05 preoperatively, and 79.42 ± 2.2 and 80.12 ± 1.33 at 3 months and 12 months, respectively. Radiological union was achieved in all patients at 3 months. Of 27 patients, only 1 patient (3.7%) had proximal migration of the osteotomy site at 6 months: the patient was asymptomatic and union was also achieved and, therefore, no surgical intervention was performed. Conclusions Tibial tubercle osteotomy during revision TKA can be a safe and reliable technique with superior outcomes and minimal complication rates.

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Background Information regarding the use of hinged implants in non-oncological conditions is limited in our region due to a lack of adequate data collection and follow-up. The purpose of this study is to evaluate mid-term results and risk factors affecting the survivorship of third-generation rotating hinge knee (RHK) patients in non-oncological conditions. Methods We retrospectively reviewed 41 single, third-generation, rotating hinge prostheses in three complex primary knee procedures and 38 revision knee surgeries in between 2007 to 2014. Implant survival was assessed using the Kaplan-Meier method. Factors influencing implant survival were identified using the log-rank test. During the study period, clinical results along with complications were assessed. Clinical outcomes were assessed by using the Knee Society Score (KSS). Results RHK arthroplasty was used in 41 patients. Out of 41 patients, a RHK was used in three patients with a complex primary deformed knee whereas in 38 patients, a RHK was used in revision arthroplasty surgery. The cumulative implant survival rate with re-revision due to any cause was found to be 87.8% (95% CI 69.2–90.1) at 5–7 years. Prosthetic joint infection, peri-prosthetic fracture and extensor mechanism complications were the commonest mode of failure. The P value was found to be significant when comparing KSS pre-operatively and post-operatively. Conclusion The cumulative implant survival rate was found to be 87.8%. Prosthetic joint infection was the commonest mode of failure in patients who underwent third-generation RHK surgery for variable indications. Being a patient with a high Charlson comorbidity index is the main risk factor associated with failure of the rotating hinge implant.

A broken intramedullary nail is a well-known complication of non-union of femur shaft fractures. Numerous surgical techniques have been presented before in patients with non-union of long bone fractures. We report the surgical technique used to perform removal of the broken distal segment of a nail in a patient who achieved uneventful union after intramedullary nailing of closed femur shaft fracture. A ball-tipped guidewire was inserted through the broken segment of the femur nail. A pre-bend plain wire was then inserted. With the help of a vise-grip, both wires were twisted in order to make a secure handle between guidewires and a broken implant. With the help of a mallet upward-directed blows were applied to extract a broken segment of the nail. We found ball-tipped guidewire technique a useful and effective technique in removing the broken distal portion of the nail.