Increased infection risk after hip hemiarthroplasty in institutionalized patients with proximal femur fracture

"Implant-associated infection after hip fracture surgery in elderly patients: Risk factors and mortality"

AIMS

Our study aimed to evaluate the prognosis of implant-related infection following hip fracture and pre-surgical, surgical and microbiological factors modifying outcomes.

METHODS

We retrospectively included patients aged 65 and older treated for infection following surgically managed hip fractures between 2012 and 2022. Periprosthetic and high-energy fractures were excluded. Data was obtained by clinical chart review, including: age, gender, Barthel index, Charlson Score, National Hip Fracture Database (NHFD) Mobility Score, surgery and infection type, causative pathogens, antimicrobial resistance, anti-biofilm antibiotic treatment and clinical situation at one-year follow up. The outcomes evaluated were failure/resolution of infection and one-year mortality.

RESULTS

We included 80 patients (67 women, 83.8 %) aged a median of 85 years (interquartile range: 78 - 88 years). Treatment failed in 38 (47.5 %) patients, and the one-year mortality was 37.5 %. Patients dying within 12 months after treatment were more likely to suffer acute vs. chronic infections (OR = 3.29 [95 %CI: 1.20-9.04]), be older and have more comorbidity, but baseline function and ambulation were not predictive. Treatment failure was higher among patients receiving non-antibiofilm controlling surgery, specifically surgical lavage (OR = 3.79 [95 %CI: 1.38-10,37]), as well as in older, more dependent patients. Receiving anti-biofilm antibiotics for more than 2 weeks was associated with less treatment failure (OR:0.32; [95 %CI: 0.13-0.80]) and 12-month mortality (OR:0.22 [95 %CI: 0.08-0.60]).

CONCLUSIONS

Antibiofilm-controlling surgery and antibiotics improve treatment success following implant-related infection after hip fracture and should be considered regardless of fracture type. Acute infections are a "second hit" for frail patients recovering from initial surgery and are associated with increased mortality.

30-day and one-year readmission rate in 11,270 patients with surgical treatment for proximal femoral fractures across Austria

Aims

Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

Methods

Data from 11,270 patients with PFFs, treated surgically (osteosyntheses, n = 6,435; endoprostheses, n = 4,835) at Austrian hospitals within a one-year period (January to December 2021) was retrieved from the Leistungsorientierte Krankenanstaltenfinanzierung (Achievement-Oriented Hospital Financing). The 30-day and one-year readmission rates were reported. Readmission risk for any complication, as well as general medicine-, internal medicine-, and surgery/injury-associated complications, and factors associated with readmissions, were investigated.

Results

The 30-day and one-year readmission rates due to any complication were 15% and 47%, respectively. The 30-day readmission rate (p = 0.001) was higher in endoprosthesis than osteosynthesis patients; this was not the case for the one-year readmission rate (p = 0.138). Internal medicine- (n = 2,273 (20%)) and surgery/injury-associated complications (n = 1,612 (14%)) were the most common reason for one-year readmission. Regardless of the surgical procedure, male sex was significantly associated with higher readmission risk due to any, as well as internal medicine-associated, complication. Advanced age was significantly associated with higher readmission risk after osteosynthesis. In both cohorts, treatment at mid-sized hospitals was significantly associated with lower readmission risk due to any complication, while prolonged length of stay was associated with higher one-year readmission risks due to any complication, as well as internal-medicine associated complications.

Conclusion

Future health policy decisions in Austria should focus on optimization of perioperative and post-discharge management of this vulnerable patient population.

Comparative analysis of pathogen distribution in patients with fracture-related infection and periprosthetic joint infection: a retrospective study

BACKGROUND

The purpose of this study is to investigate the microbial patterns of periprosthetic joint infection (PJI) and fracture-related infection (FRI), and guide for the formulation of more accurate empirical antimicrobial regimens based on the differences in pathogen distribution.

METHODS

A comparative analysis of pathogen distribution was conducted between 153 patients (76 with PJI and 77 with FRI). Predicted analyses against isolated pathogens from two cohorts were conducted to evaluate the best expected efficacy of empirical antimicrobial regimens (imipenem + vancomycin, ciprofloxacin + vancomycin, and piperacillin/tazobactam + vancomycin).

RESULTS

Our study found significant differences in pathogen distribution between the PJI and FRI cohorts. Staphylococci (61.3% vs. 31.9%, p = 0.001) and Gram-negative bacilli (GNB, 26.7% vs. 56.4%, p < 0.001) were responsible for the majority of infections both in the PJI and FRI cohorts, and their distribution in the two cohorts showed a significant difference (p < 0.001). Multi-drug resistant organisms (MDRO) were more frequently detected in the FRI cohort (29.3% vs. 44.7%, p = 0.041), while methicillin-resistant coagulase-negative Staphylococci (MRCoNS, 26.7% vs. 8.5%, p = 0.002) and Canidia albicans (8.0% vs. 1.1%, p = 0.045) were more frequently detected in the PJI cohort. Enterobacter spp. and Acinetobacter baumannii were detected only in the FRI cohort (11.7% and 8.5%, respectively).

CONCLUSIONS

Staphylococci and GNB were responsible for the majority of infections in both PJI and FRI. Empirical antimicrobial therapy should focus on the coverage of Staphylococci in PJI and GNB in FRI, and infections caused by MDROs should be more vigilant in FRI, while the high incidence of MRCoNS in PJI should be noted, which could guide for the formulation of more accurate empirical antimicrobial regimens. Targeted therapy for FRI caused by A. baumannii and PJI caused by C. albicans needs to be further investigated. Our study reports significant differences in pathogen distribution between the two infections and provides clinical evidence for studies on the mechanism of implant-associated infection.

A retrospective study of risk factors, causative micro-organisms and healthcare resources consumption associated with prosthetic joint infections (PJI) using the Clinical Practice Research Datalink (CPRD) Aurum database

BACKGROUND

Prosthetic joint infection (PJI) is a serious complication after joint replacement surgery and it is associated with risk of mortality and morbidity along with high direct costs.

METHODS

The Clinical Practice Research Datalink (CPRD) data were utilized to quantify PJI incidence after hip or knee replacement up to 5 years after implant and a variety of risk factors related to patient characteristics, medical and treatment history along with characteristics of the original surgery were analyzed through Cox proportional hazard.

RESULTS

221,826 patients (individual joints 283,789) met all the inclusion and exclusion criteria of the study; during the study follow-up period (5 years), 707 and 695 PJIs were diagnosed in hip and knee, respectively. Patients undergoing joint replacement surgery during an unscheduled hospitalization had greater risk of PJI than patients whose surgery was elective; similarly, the risk of developing PJI after a secondary hip or knee replacement was about 4 times greater than after primary arthroplasty when adjusted for all other variables considered. A previous diagnosis of PJI, even in a different joint, increased the risk of a further PJI. Distribution of average LoS per each hospitalization caused by PJI exhibited a right skewed profile with median duration [IQR] duration of 16 days [8-32] and 13 days [7.25-32] for hip and knee, respectively. PJIs causative micro-organisms were dependent on the time between initial surgery and infection offset; early PJI were more likely to be multispecies than later (years after surgery); the identification of Gram- pathogens decreased with increasing post-surgery follow-up.

CONCLUSIONS

This study offers a contemporary assessment of the budgetary and capacity (number and duration of hospitalizations along with the number of Accident and Emergency (A&E) visits) posed by PJIs in UK for the national healthcare system (NHS). The results to provide risk management and planning tools to health providers and policy makers in order to fully assess technologies aimed at controlling and preventing PJI. The findings add to the existing evidence-based knowledge surrounding the epidemiology and burden of PJI by quantifying patterns of PJI in patients with a relatively broad set of prevalent comorbidities.

Pre-operative Colonization by Staphylococcus aureus and Cephalosporin Non-susceptible Bacteria in Patients with Proximal Femoral Fractures

Objective  To estimate the frequency of Staphylococcus aureus and cephalosporin nonsusceptible bacteria colonization in patients with proximal femoral fracture during preoperative hospitalization. Methods  Prevalence and incidence assessment in 63 hospitalized patients over 1 year. The median time of pretreatment hospitalization was 12 days. Samples were collected from the nostrils, groin skin and anal mucosa during the pretreatment hospitalization and were tested by the disc-diffusion technique. Results  The hospital colonization incidence and the prevalence of positive results were 14.3 and 44.4% for S. aureus ; 3.2 and 6.4% for meticillin-resistant S. aureus ; 28.6 and 85.7% for meticillin-resistant coagulase-negative Staphylococcus ; 28.6 and 61.9% for cefazolin nonsusceptible Enterobacteriaceae (KFNSE); and 20.6 and 28.6% for cefuroxime nonsusceptible Enterobacteriaceae (CXNSE). In addition, factors such as to the duration of the pretreatment hospitalization period, being non-walker before fracture, antimicrobial use, American Society of Anesthesiologists (ASA) 4 surgical risk, and previous hospitalization, were related to an increase in the incidence of hospital acquisition and prevalence of colonization by the evaluated strains. The prevalence of colonization by KFNSE was three times higher than by CXNSE on admission, and twice as high at the time of fracture treatment. Conclusion  There was a high incidence of hospital colonization and prevalence of colonization by all strains studied, which may guide the indication of prophylactic measures for infection.

Patients at a high risk of PJI: Can we reduce the incidence of infection using dual antibiotic-loaded bone cement?

Prosthetic joint infection (PJI) is one of the most devastating complications of orthopedic surgery. However, not all patients are equally at the risk of severe infection. The incidences of PJI vary with the host and surgery-related risk factors. It is now generally accepted that some important medical comorbidities may predispose the patients to a high risk of PJI. Time-consuming and invasive surgical procedures, such as revision arthroplasties, are also associated with a high incidence of PJI, presumably due to the increased risk of surgical site contamination. Effective infection-preventing strategies should begin with identifying and optimizing the patients at a high risk of infection prior to surgery. Optimizing the operating room environment and antibiotic prophylaxis are also essential strategies that help minimize the overall incidence of infection in orthopedic surgery. The ideal antibiotic prophylaxis is still under debate, and discussions have emerged about whether variations or adjustments to the standard protocol are justified in patients at a high risk of infection. This also includes evaluating the possible benefits and risks of using high-dose dual antibiotic-loaded bone cement instead of low-dose single antibiotic-loaded bone cement in arthroplasty. This review summarizes the evidence showing that the combination of two local antibiotics in bone cement exerts a strong and longer-lasting antimicrobial effect against PJI-associated pathogens. This conclusion is consistent with the preliminary clinical studies showing a low incidence of PJI in high-risk patients undergoing cemented hemiarthroplasty, cemented revision, and primary arthroplasty if dual ALBC is used. These results may encourage clinicians to consolidate this hypothesis in a wider clinical range.

Management of Periprosthetic Joint Infections After Hemiarthroplasty of the Hip: A Critical Analysis Review

➢

Periprosthetic joint infection (PJI) following hip hemiarthroplasty (HA) is a devastating complication, incurring immense health-care costs associated with its treatment and placing considerable burden on patients and their families. These patients often require multiple surgical procedures, extended hospitalization, and prolonged antimicrobial therapy.

➢

Notable risk factors include older age, higher American Society of Anesthesiologists (ASA) score, inadequate antibiotic prophylaxis, non-antibiotic-loaded cementation of the femoral implant, longer duration of the surgical procedure, and postoperative drainage and hematoma.

➢

Although the most frequent infecting organisms are gram-positive cocci such as Staphylococcus aureus, there is a higher proportion of patients with gram-negative and polymicrobial infections after hip HA compared with patients who underwent total hip arthroplasty.

➢

Several surgical strategies exist. Regardless of the preferred surgical treatment, successful management of these infections requires a comprehensive surgical debridement focused on eradicating the biofilm followed by appropriate antibiotic therapy.

➢

A multidisciplinary approach led by surgeons familiar with PJI treatment and infectious disease specialists is recommended for all cases of PJI after hip HA to increase the likelihood of treatment success.

Determination of risk factors of postoperative pneumonia in elderly patients with hip fracture: What can we do?

BACKGROUND

Postoperative pneumonia is a serious complication in elderly patients with hip fracture. It is necessary to identify the influencing factors of postoperative pneumonia in patients with hip fracture.

METHODS

Elderly patients with hip fractures admitted to a tertiary hospital in China from January 1, 2020 to August 31, 2021 were included. The characteristics of patients with and without postoperative pneumonia were evaluated and compared. Logistic multivariate regression analyses were conducted to assess the risk factors of postoperative pneumonia.

RESULTS

267 patients with hip fracture were included, the incidence of postoperative pneumonia in patients with hip fracture was 13.11%. There were significant differences in the age, diabetes mellitus, anemia, hypoalbuminemia, anesthesia method and duration of surgery between infection and no infection group, no significant differences in the gender, BMI, hypertension, hyperlipidemia, type of fracture, preoperative oxygen saturation, white blood cell count, platelet count, red blood cell count, creatinine, alanine aminotransferase, aspartate aminotransferase, estimated blood loss during surgery were detected between infection and no infection group. Logistic regression analysis showed that age≥70y (OR2.326, 95%CI1.248~3.129), diabetes mellitus (OR2.123, 95%CI1.021~3.551), anemia (OR3.199,95%CI1.943~5.024), hypoalbuminemia (OR2.377, 95%CI1.211~3.398), general anesthesia (OR1.947, 95%CI1.115~3.038), duration of surgery≥120min (OR1.621, 95%CI1.488~2.534) were the risk factors of postoperative pneumonia in elderly patients with hip fracture (all p<0.05). Escherichia Coli (33.33%), Klebsiella pneumoniae (28.57%), Staphylococcus aureus (21.43%) were the most common bacteria of pulmonary infection.

CONCLUSION

There are many risk factors for postoperative pneumonia in elderly patients with hip fractures after surgery. In clinical practice, medical workers should take targeted interventions for those risk factors to reduce postoperative pneumonia.

Thickness of the Subcutaneous Fat as a Risk Factor for Surgical Site Infection Following Fragility Hip Fracture Surgery

INTRODUCTION

Surgical site infection (SSI) following fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality.

SIGNIFICANCE

Prediction of patients at risk for SSI is fundamental. We aimed to determine whether subcutaneous radiographic fat measurement (SRM) is associated with increased SSI risk.

METHODS

A retrospective case-control comparison of SRMs at 3 locations around the hip. Patients diagnosed with SSI in the first post-operative year were matched with age, gender, surgical year, Charlsons' co-morbidity index score, and surgical type controls, not diagnosed with SSI, at a 1:2 ratio. Measurements included the distance between (1) the sourcil to skin surface (SS), (2) the tip of the greater trochanter to skin surface (TGTS), and (3) the most prominent lateral aspect of the greater trochanter to skin surface.

RESULTS

1430 patients were operated during the study period, of whom 45 patients presented with a diagnosis of SSI and compared to 90 controls. Infections occurred 27.4 ( ± 24.8) days following surgery. SRM significantly differed between groups, and all were higher in the study group; SS, 86.8 ± 25.5 cm vs 74.2 ± 15.3 cm; TGTS, 59.8 ± 26.3 cm vs 47.0 ± 15.8 cm; and LGTS, 45.4 ± 25.1 cm vs 33.2 ± 15.1 cm (P = .003, .004, and .004, respectively). Intraclass correlation coefficients (intra-rater) were high for all measurements (.999 for all). Intraclass correlation coefficients (inter-rater) for SS, TGTS and LGTS were high, .749 (.663.815), .792 (.719.847) and .817 (.751.866), respectively.

CONCLUSIONS

SRMs were found to be a valid and reproducible tool for predicting high risk of SSI in geriatric patients sustaining FHFs.

LEVEL OF EVIDENCE

III.

Periprosthetic joint infections in femoral neck fracture patients treated with hemiarthroplasty – should we use antibiotic-loaded bone cement?

BACKGROUND

Hemiarthroplasty is the most common treatment in elderly patients with displaced intra-capsular femoral neck fracture (FNF). Prosthetic joint infection (PJI) is one of the most feared and frequent complications post-surgery because of the frail health status of these patients and the need for fast track surgery. Therefore, priorities should lie in effective preventive strategies to mitigate this burden.

AIM

To determine how much the implementation of the routine use of antibiotic-loaded bone cement (ALBC) as a relatively easy-to-apply amendment to the surgical practice reduces the infection rate in our hemiarthroplasty cohort.

METHODS

We retrospectively assessed all demographic, health status and treatment-related data of our FNF patients undergoing cemented hemiarthroplasty in the period from 2011 to 2017; 241 patients were further analyzed after exclusion of patients with cancer-related sequelae and those who died before the end of the 1-year observation period. The PJI rate as diagnosed on basis of the Musculoskeletal Infection Society (MSIS) criteria 2011 was determined for each included patient and compared in function of the bone cement used for hip stem fixation. Patients were split into a group receiving a plain bone cement in the period from January 2011 to June 2013 (non-ALBC group) and into a group receiving an ALBC in the period July 2013 to December 2017 (ALBC group). Data analysis was performed with statistical software. We further calculated the cost-efficacy of the implementation of routine use of ALBC in the second group balancing the in-hospital infection related treatment costs with the extra costs of use of ALBC.

RESULTS

In total 241 FNF patients who received cemented hemiarthroplasty in the period from January 2011 to January 2017 were eligible for inclusion in this retrospective study. There were 8 PJI cases identified in the ALBC group among n = 94 patients, whereas 28 PJI cases were observed in the non-ALBC group among n = 147 patients. The statistical analysis showed an infection risk reduction of 55.3% (in particular due to the avoidance of chronic delayed infections) in the ALBC group (95%CI: 6.2%-78.7%; P = 0.0025). The cost-evaluation analysis demonstrated a considerable cost saving of 3.500 € per patient, related to the implementation of routine use of ALBC in this group.

CONCLUSION

Use of ALBC is a potent infection preventive factor in FNF patients receiving cemented hemiarthroplasties. It was further found to be highly cost-effective.

Role of asymptomatic bacteriuria on early periprosthetic joint infection after hip hemiarthroplasty. BARIFER randomized clinical trial

PURPOSE

To evaluate preoperative asymptomatic bacteriuria (ASB) treatment to reduce early-periprosthetic joint infections (early-PJIs) after hip hemiarthroplasty (HHA) for fracture.

METHODS

Open-label, multicenter RCT comparing fosfomycin-trometamol versus no intervention with a parallel follow-up cohort without ASB.

PRIMARY OUTCOME

early-PJI after HHA.

RESULTS

Five hundred ninety-four patients enrolled (mean age 84.3); 152(25%) with ASB (77 treated with fosfomycin-trometamol/75 controls) and 442(75%) without. Despite the study closed without the intended sample size, ASB was not predictive of early-PJI (OR: 1.06 [95%CI: 0.33-3.38]), and its treatment did not modify early-PJI incidence (OR: 1.03 [95%CI: 0.15-7.10]).

CONCLUSIONS

Neither preoperative ASB nor its treatment appears to be risk factors of early-PJI after HHA. ClinicalTrials.gov Identifier: Eudra CT 2016-001108-47.

Periprosthetic Joint Infection Prophylaxis in the Elderly after Hip Hemiarthroplasty in Proximal Femur Fractures: Insights and Challenges

We review antibiotic and other prophylactic measures to prevent periprosthetic joint infection (PJI) after hip hemiarthroplasty (HHA) surgery in proximal femoral fractures (PFFs). In the absence of specific guidelines, those applied to these individuals are general prophylaxis guidelines. Cefazolin is the most widely used agent and is replaced by clindamycin or a glycopeptide in beta-lactam allergies. A personalized antibiotic scheme may be considered when colonization by a multidrug-resistant microorganism (MDRO) is suspected. Particularly in methicillin-resistant Staphylococcus aureus (MRSA) colonization or a high prevalence of MRSA-caused PJIs a glycopeptide with cefazolin is recommended. Strategies such as cutaneous decolonization of MDROs, mainly MRSA, or preoperative asymptomatic bacteriuria treatment have also been addressed with debatable results. Some areas of research are early detection protocols in MDRO colonizations by polymerase-chain-reaction (PCR), the use of alternative antimicrobial prophylaxis, and antibiotic-impregnated bone cement in HHA. Given that published evidence addressing PJI prophylactic strategies in PFFs requiring HHA is scarce, PJIs can be reduced by combining different prevention strategies after identifying individuals who will benefit from personalized prophylaxis.

Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence

In view of the demographic changes and projected increase of arthroplasty procedures worldwide, the number of prosthetic joint infection cases will naturally grow. Therefore, in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance. In the absence of a “miracle weapon” priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks, the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen. Instead of a “one size fits all” philosophy, it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient- and procedure-related risk factors. A stronger focus on the local application mode via use of high dose dual antibiotic-loaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre. The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.

Relationship between skin and urine colonization and surgical site infection in the proximal femur fracture: a prospective study

PURPOSE

Antibiotic prophylaxis is routinely used in the surgical management of proximal femur fractures. The role of bacterial colonization of the skin and urine in the development of deep surgical site infections (SSI) is yet to be elucidated. This study aimed to evaluate the role of previous skin and urine colonization in the development of deep SSI after a proximal femoral fracture surgery.

METHODS

We conducted a prospective observational study in 326 patients > 64 years old, who were scheduled to surgery. Cultures from skin samples of the surgical site and from urine were performed prior to the procedure, and cefazoline was administered as prophylaxis.

RESULTS

Skin microbiota was isolated in 233 (71.5%) cases; 8 (2.5%) samples were positive for other bacteria, and 85 (26%) were negative. Of 236 urine samples, 168 were negative or contaminated (71.2%), and 68 (28.8%) were positive, being 58/236 for Enterobacterales (24.6%). Acute deep SSI were diagnosed in nine out of 326 patients (2.7%), and two (22%) were infected by Gram-negative bacilli. Of the 9 cases, normal skin microbiota was isolated in 7 (78%), and the remaining two were negative. Seven cases had negative or contaminated urine cultures, and the one with E. coli did not correlate with SSI bacteria.

CONCLUSION

In our elderly hip fracture population, most patients harbored normal skin microbiota, and Enterobacterales urine cultures were positive in one-quarter of cases. There was no relationship between skin colonization, urine culture, and deep SSI. We therefore do not believe that our patients would benefit from modifying the current antibiotic prophylaxis.

Surgical Site Infections in Elderly Fragility Hip Fractures Patients Undergoing Warfarin Treatment

OBJECTIVES

Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients.

DESIGN

Retrospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Individuals 65 years of age and older with fragility hip fractures.

INTERVENTION

Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered.

MAIN OUTCOME MEASURES

Postoperative SSIs.

RESULTS

Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ.

CONCLUSIONS

Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Curative treatment of prosthetic joint infection in patients younger than 80 vs. 80 or older

OBJECTIVE

Prosthetic joint infection (PJI) is a serious complication of joint replacement surgery. The major pharmacological and surgical treatments required by PJI increase the risk of peri-operative complications in elderly patients. The increase in life expectancy combined with procedural advances make these treatments possible even in the oldest patients. Here, our objective was to compare the characteristics and outcomes of curative PJI treatment in patients < 80 years vs. ≥ 80 years.

METHODS

A prospective single-center design was used to compare the characteristics and outcomes of curative treatment for hip or knee PJI in patients < 80 years and ≥ 80 years admitted in 2004-2014.

RESULTS

Of 765 patients admitted for PJI, 590 were < 80 years and 124 were ≥ 80 years. Medical history and comorbidities were similar in the two groups. The older group had a significantly higher proportion of patients with American Society of Anesthesiologists Scores ≥ 3 and with streptococcal infection (20% vs. 13%, P < 0.05). After complete surgical excision and prolonged antibiotic therapy, the only event whose frequency differed significantly between the two groups was PJI-related death, which was more common in the older patients (6.5% vs. 0.8%, P < 0.05). The 2-year survival rate after one-stage exchange arthroplasty was > 90% in the  ≥80 year group.

CONCLUSION

Patients aged 80 years or older are eligible for the same curative pharmacological and surgical PJI treatments used in their younger counterparts. Before surgery, the risk/benefit ratio of the major surgical procedure required to treat PJI must be assessed on a case-by-case basis.

Evaluation and Management of Failed Hemiarthroplasty

Hemiarthroplasty is a common procedure for treatment of displaced femoral neck fractures in low-demand patients. As hip fracture incidence continues to increase, the need for revision hemiarthroplasty is also expected to increase. Multiple etiologies can result in a failed hemiarthroplasty, including persistent pain, infection, instability, leg-length discrepancy, and trauma. Preoperative clinical, radiographic, and laboratory assessments are critical in determining the etiology of the painful hemiarthroplasty. The standard of care for surgical management of failed hemiarthroplasty is conversion to a total hip arthroplasty. However, establishing the etiology preoperatively is essential to planning before treating the failed hemiarthroplasty.

Prosthesis retention after an infected hip prosthesis: hip fractures versus primary total hip prosthesis, data from 1998 - 2015

Background: A prosthetic joint infection (PJI) is a serious complication and specifically a burden for patients after hip fracture surgery, as they are mostly frail elderly patients with multiple comorbidities. Since treatment protocols are lacking there is a need to evaluate current practice. Aim: To evaluate the difference in prosthesis retention after an infected primary total hip replacement (THR) compared to PJI after hip prosthesis surgery performed for a hip fracture. Methods: We retrospectively collected data of patients who developed PJI after primary THR or after hip fracture surgery (THR or hemiarthroplasty) in the Westfriesgasthuis Hospital between 1998 and 2015. Main outcome variables were DAIR treatment and prosthesis retention. Findings: A PJI developed in 48 patients after primary THR and in 23 patients after hip fracture surgery. DAIR was performed in all patients after primary THR and in 87.0% of patients after hip fracture surgery (p<0.05). In 11.4% of patients after primary THR, revision surgery was performed within 1 year after PJI compared to 34.8% after hip fracture surgery (p<0.05). Only 2.1% of patients deceased within 1 year after infection of primary THR compared to 34.8% after hip fracture surgery (p<0.05). Conclusion: Our results showed that prosthesis retention in patients with a PJI after hip fracture surgery is 23% lower than in patients with a PJI after primary THR. This is probably due to the fact that patients who experience a hip fracture are mostly frail elderly with multiple comorbidities and therefore less able to conquer a PJI.

Peri-operative antibiotic treatment of bacteriuria reduces early deep surgical site infections in geriatric patients with proximal femur fracture

PURPOSE

The aim of this study was to conduct a re-evaluation of current strategies for peri-operative prophylaxis of infections in orthopaedic surgery of geriatric patients (≥65 years) with proximal femoral fractures (PFF).

METHODS

Between 01/2010 and 08/2014 all post-operative infections after stabilization of PFF of 1,089 geriatric patients were recorded retrospectively. All patients pre-operatively received a single dose of 1.5 g cefuroxime (group 1). These were compared to prospectively determined post-operative rates of surgical site infection (SSI) of 441 geriatric patients, which were operated on between 09/2014 and 03/2017 due to PFF. In this second group we investigated the urinary tract on admission. Bacteriuria was treated with the pre-operative single dose of 1.5 g cefuroxime along with ciprofloxacin for five days, beginning on admission. Level of significance was set to p < 0.05.

RESULTS

A total of 141 patients of group 2 had a bacteriuria. Seventy-seven of these patients revealed biochemical signs of manifest urinary tract infection. Multi-resistant pathogens were found in 15 patients and pathogens were cefuroxime-resistant in 37. The differences of SSI after at least three months were 2.1% in group 1 and 0.45% in group 2 for all patients with surgery of PFF (p < 0.02) and for those with arthroplasty (p < 0.037) significant.

CONCLUSIONS

The immediate antibiotic therapy of a prevalent bacteriuria for five days decreases the risk of SSI after surgery of PFF. Our single-centre study can only point out the problem of prevalent reservoirs of pathogens and the need for treatment. Evidence-based therapy concepts (indications of antibiotics, classes, duration) have to be developed in multi-centric and prospective studies.

Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur

AIMS

Surgical site infection can be a devastating complication of hemiarthroplasty of the hip, when performed in elderly patients with a displaced fracture of the femoral neck. It results in a prolonged stay in hospital, a poor outcome and increased costs. Many studies have identified risk and prognostic factors for deep infection. However, most have combined the rates of infection following total hip arthroplasty and internal fixation as well as hemiarthroplasty, despite the fact that they are different entities. The aim of this study was to clarify the risk and prognostic factors causing deep infection after hemiarthroplasty alone.

PATIENTS AND METHODS

Data were extracted from a prospective hip fracture database and completed by retrospective review of the hospital records. A total of 916 patients undergoing a hemiarthroplasty in two level II trauma teaching hospitals between 01 January 2011 and 01 May 2016 were included. We analysed the potential peri-operative risk factors with univariable and multivariable logistic regression analysis.

RESULTS

A total of 92 patients (10%) had a surgical site infection, and 44 (4.9%) developed a deep infection. After univariable analyses, the multivariable model showed that the level of experience of the surgeon measured by the number of hemiarthroplasties performed per year was a significant prognostic factor (odds ratio (OR) 0.93, p = 0.042) for the development of an infection. Secondly, the development of a haematoma (OR 9.6, p < 0.001), a re-operation (OR 4.7, p = 0.004) and an operating time of < 45 mins (OR 5.1, p = 0.002) or > 90 mins (OR 2.7, p = 0.034) were also significant factors.

CONCLUSION

There was a significant association between the experience of the surgeon and the rate of deep infection. Secondly, a haematoma, a re-operation and both shorter and longer operating times were associated with an increased risk of deep infection after hemiarthroplasty. No association was found between deep infection and the anatomical approach, the time when surgery was undertaken and the use of a drain. Cite this article: Bone Joint J 2017;99-B:1088-94.