Management of periprosthetic joint infection: the current knowledge: AAOS exhibit selection

One-Stage Revision Using Cementless Reconstruction for Chronically Infected Total Hip Arthroplasty: An Average of 11 Years of Follow-Up

BACKGROUND

Although interest in one-stage revision has increased in recent years, long-term follow-up reports remain notably scarce. This study aimed to present the 11-year outcomes of cementless one-stage revision for chronically infected total hip arthroplasty (THA), including infection-free survivorship, radiographic and clinical outcomes, and complications.

METHODS

A retrospective analysis conducted between 2010 and 2016 included 126 patients who had chronically infected THA and underwent one-stage revision using cementless reconstruction. Kaplan-Meier survival analysis was used to assess postoperative survival, while Cox regression analysis identified risk factors for reinfection. Updated postoperative imaging, Harris Hip Scores (HHS), and complications were recorded. Successful infection treatment was defined as the absence of clinical symptoms of infection during follow-up.

RESULTS

During a mean follow-up period of 11 years (range, eight to 14), 16 patients experienced infection recurrence, resulting in a 10-year infection-free survival rate of 85.4%. Cox regression analysis identified age ≥ 65 years (HR [hazard ratio] 3.0, 95% CI [confidence interval] 1.2 to 8.6; P = 0.02) and American Society of Anesthesiologists (ASA) grade III (HR 3.1, 95% CI 1.1 to 8.1; P = 0.03) as significant risk factors for re-infection. The presence of a sinus tract, prolonged operative time, culture-negative (Periprosthetic joint infection) PJI, methicillin-resistant pathogen infection, and prior surgery for infection were not associated with recurrence. Among the patients, two experienced recurrent dislocations and one had aseptic loosening, leading to a 10-year aseptic re-revision-free survival rate of 97.0%. The mean postoperative HHS at the latest follow-up was 77.9 points (range, 68.5 to 86.7; P < 0.001). Complications occurred in 26 patients (23.4%), and the 10-year reoperation-free survival rate was 78.7%.

CONCLUSION

A one-stage revision using cementless reconstruction for infected THA demonstrated a favorable infection control rate and sustained satisfactory clinical outcomes. However, further studies with higher-level evidence are needed to validate these findings.

Efficacy of Different Irrigation Solutions on Bacterial Biofilm in Periprosthetic Joint Infections: A Systematic Review and Network Meta-Analysis

Background: Chemical debridement with an irrigating solution associated with surgical debridement has proven to be useful in the treatment of periprosthetic joint infection (PJI). The aim of the study was to perform a systematic review and meta-analysis of the current literature regarding the efficacy of different irrigation solutions on bacterial biofilm. Methods: This study was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Network Meta-Analysis (PRISMA-NM) checklist. A Network Meta-Analysis was performed to analyze which irrigation solution achieved a greater reduction in colony-forming units (CFU) after specific exposure times in vitro. Effect size was measured using the log ratio of means (logRoM) and 95% confidence intervals (95% CI). The rank probability for each treatment was calculated using P-values. Results: After discarding duplicates, screening, and reviewing the full texts, four studies with 10 irrigation solutions for different exposure durations were included. The solutions were studied on mature biofilms of the most frequent bacteria. The greatest effect was achieved with 10% povidone-iodine for 5 min (est.: -12.02; 95% CI: -14.04, -9.99). The best-ranked solutions were 10% povidone-iodine for 5, 3, and 1 min (respective p-values: 0.977, 0.932, 0.887), and its combination with hydrogen peroxide for 3 min (p-score: 0.836). Povidone-iodine 0.3% for 5 min completed the top five ranked solutions in this study (p-score: 0.761). Conclusions: Our results show that 10% povidone-iodine is the best antiseptic solution when studied in vitro in the context of prosthetic joint infection. Further research in these areas is necessary to determine whether these results are reproducible with in vivo situations.

Two-stage exchange of infected total hip arthroplasty with a dual-mobility cup is associated with a low instability rate

INTRODUCTION

The two-stage management of hip Prosthetic Joint Infection (PJI) is faced with a high rate of dislocation. Dual mobility (DM) cups have proved effective in reducing the risk of dislocation, but few data are available on the two-stage management of hip PJI. The objectives of this retrospective cohort study were to analyze the rate of dislocation, and the rate of recurrent dislocation and to identify risk factors for dislocation. Our hypothesis was that the use of a DM cup during a two-stage replacement had a low instability rate.

METHODS

Data from 70 two-stage changes with DM cup reimplantation performed in our centre between 2011 and 2020 were retrospectively collated. The mean age was 69 years [18-93], with a mean follow-up of 3.4 years [1.5-9.6]. Dislocation rates and risk factors for prosthetic instability were collected. Univariate and multivariate analyses were performed to identify risk factors favouring prosthetic instability.

RESULTS

The rate of dislocation at the last follow-up was 8.6% (6/70), including 4.3% (3/70) in patients with no infection recurrence. The rate of recurrent dislocation was 0% when infection was controlled. The occurrence of spacer dislocation, the presence of immunosuppressive and antiaggregant medication, the local grade of the McPherson score and infection treatment failure were associated with the occurrence of a dislocation. No risk factors were identified in the multivariate analysis.

DISCUSSION

Compared with the rates reported in the literature, the use of a DM cup seems indicated in this context in order to lower the risk of recurrent dislocation. Preventing spacer dislocation and infection recurrence seems to be essential to avoid the risk of instability of the future prosthetic hip.

Microbiologic features of prosthetic joint infections at a tertiary referral orthopaedic unit

BACKGROUND

Prosthetic joint infections (PJI) are a potential devasting consequence of arthroplasty surgery. Knowledge of the causative organism and antimicrobial sensitivity increases eradication success rates for PJI.

AIMS

This study aimed to: 1) Observe the PJI microbiome at a tertiary referral arthroplasty unit; 2) Make comparison to similar published observations; and; 3) Establish empiric local antibiotic PJI guidelines.

METHODS

All patients with positive tissue cultures for PJIs over a 4 year period were included. An electronic microbiology laboratory database search was performed to identify isolated microorganisms, sensitivities and resistances. Time from index procedure to PJI onset was recorded. The identified PJI microbiome was compared to current literature.

RESULTS

86 patients involving 88 joints were included. 56% (n = 49) related to hip, 42% (n = 37) to knee and 2% (2) to shoulder arthroplasty procedures. Coagulase Negative Staphylococci (CoNS) were isolated in 32% of cases, Staphylococcus aureus (SA) in 23%, Enterococcus species and Streptococcus species in 9.0%. 19% of case occurred within 3 months of index surgery, 17% from 3-12 months and 64% after 12 months. The microbiome identified varied comparable studies.

CONCLUSION

This study describes a local PJI microbiome with contrasting results from comparable studies. Empiric antibiotic guidelines have been established to target treatment and a local PJI register has since been established to improve patient outcomes and antimicrobial stewardship in an era of antibiotic resistance.

Quadriceps tear, infection and dislocation: Three rare complications after total knee arthroplasty. A case report

INTRODUCTION

Infection after a total knee arthroplasty (TKA) is one of the most severe complications, with an incidence that ranged from 0,5 % to 1,8 %, while the incidence of a quadriceps tendon tear after total knee arthroplasty range from 0.1 % to 1.1 %. Dislocation of a TKA is another rare but very serious complication with an incidence of 0.5 %. After all, the association of these three complications, that quickly occur together, is extremely rare condition.

PRESENTATION OF CASE

Ninety years old man underwent to TKA for right knee osteoarthritis. During rehabilitation, the patient had quadriceps tendon rupture and underwent to tenorrhaphy. Three months after tenorrhaphy, on suspicion of infection, the patient received a surgical debridement. At this time total knee prosthesis was well fixed and was not removed. After another five months, the patient felt again and the radiographs of the right knee showed a posterior dislocation of the TKA treated by closed reduction in operating room, under general anesthesia. At the latest follow-up, clinical and radiological examinations showed good alignment of the TKA prosthesis, without loosening and good functional capacity.

DISCUSSION

Orthopedic surgical treatment in an elderly patient could expose to many complications. We could speculate that musculo-tendinous lesion and infection favored the TKA dislocation.

CONCLUSION

Infection, tendon injuries and dislocation are serious complications after TKA. Poor outcomes are often described for each of these complications in the current literature, however our patient recovered a good quality of life after treatment, despite the complexity of these complications and the old age.

Reinfection Patterns Following Two-Stage Exchange for Periprosthetic Joint Infection: A Retrospective Analysis

BACKGROUND

Periprosthetic joint infection (PJI) is a challenging complication following total joint arthroplasty. A two-stage exchange has been the gold standard in the treatment of chronic PJI. However, when this fails, further treatment options become limited. In patients who fail two-stage exchange, the reinfecting organism is different from the original in 50 to 80% of the occurrences. This study aimed to understand reinfection patterns in an attempt to better predict reinfecting organisms to improve the management of PJI.

METHODS

A retrospective query of our institution's PJI registry identified 185 patients (188 procedures, 110 knees, and 78 hips) who underwent a first-time two-stage exchange for culture-positive chronic PJI of total knee and hip arthroplasties from January 2010 to December 2020. Patients who had polymicrobial infections, culture-negative results, or fungal infections were excluded. The primary outcome variable was reoperation for reinfection and comparing the index organism to the reinfecting organisms.

RESULTS

Of the 188 procedures, 31 (16.5%) failed due to reinfection. Among reinfections, 30 (96.8%) were gram-positive, with Staphylococcus aureus species accounting for 22 (71.0%) of the cases. The most common organisms cultured were for methicillin-sensitive S. Aureus, methicillin-resistant S. Aureus, coagulase-negative staphylococcus, and streptococcus. Of reinfections, 19 (61.3%) had a different organism, eight (25.8%) had the same organism, and four (12.9%) were culture-negative. Patients experiencing reinfection were significantly younger (P = 0.012), with no other patterns or predictors identified.

CONCLUSIONS

The majority of reinfections following a two-stage exchange for PJI occur with a different organism than the index infection. We did not find a reliable method to predict the reinfecting organisms based on the initial infecting organism alone. However, the same four gram-positive organisms were the most frequently encountered in both the primary infection and the reinfection. Further research is required to understand factors contributing to reinfection and help guide prevention strategies.

A "1.5-Stage" Spacer Construct Using Revision Components for the Management of Periprosthetic Joint Infection of the Knee

BACKGROUND

The two-stage surgical protocols used for the treatment of periprosthetic joint infection following total knee arthroplasty are associated with marked patient morbidity. As such, alternatives, such as durable "1.5-stage" spacer constructs, have gained popularity. We sought to describe the outcomes of a novel "1.5-stage" spacer construct utilizing revision stemmed-tibia implants.

METHODS

Patients who underwent a "1.5-stage" for the management of a knee periprosthetic joint infectionat our institution were screened for inclusion. A "1.5-stage" was defined as a spacer placed with the intent of not performing a second stage, without the use of press-fit stems or cemented intramedullary fixation as is often done during a single-stage protocol. Procedures were categorized into two groups based on construct type: (1) hand-made constructs utilizing all-polyethylene tibial components; or (2) constructs utilizing stemmed-revision components precoated with cement before insertion. Patient demographics, comorbidities, and surgical details were collected and reported. The two-year Kaplan-Meier survival estimates for all-cause revision, revision for spacer loosening, and revision due to infection recurrence were reported. In total, 46 "1.5-stage" procedures were identified, including 12 handmade and 34 stemmed-revision constructs.

RESULTS

The stemmed-revision cohort was less likely to undergo reoperation for any reason (17.6 versus 50.0%, P = 0.028) or a revision for spacer loosening (0.0 versus 25.0%, P = 0.003) compared to the hand-made cohort. There were no differences with respect to infection recurrence or time to revision. The 2-year survival from revision for loosening was higher in the stemmed cohort compared to the handmade cohort though not statistically different (100%, 95% CI [confidence interval]: 2.5 to 100.0 versus 72.9%, 95% CI: 26.3 to 96.6%, P = 0.330).

CONCLUSIONS

A "1.5-stage" spacer construct using stemmed-revision components was associated with promising short-term results. Durable spacer constructs may be a viable option for select patients; however, longer-term follow-up is needed to identify patients who stand to benefit the most from this technique.

Rethinking Repeat Two-Stage Knee Exchange Arthroplasty: Outcomes, Risks, and Decision-Making

BACKGROUND

Chronic periprosthetic joint infection (PJI) presents a major challenge in knee arthroplasty, with varying success rates reported for two-stage exchange arthroplasty (EA) and a lack of consensus on managing failures from such procedures. This study evaluated repeat two-stage EA outcomes for knee PJI after initial treatment failure to identify the risk factors for reimplantation unsuitability and reinfection.

METHODS

We analyzed 114 patients who underwent repeat EA for chronic knee PJI between 2010 and 2018. From an initial cohort of 1,351 patients, we excluded 231: 18 for incomplete records or protocol non-compliance and 213 for prior revisions. Among the remaining 1,119 patients, 150 experienced reinfection. After excluding 36 who did not undergo repeat EA, the final cohort comprised 114 patients. Outcomes were evaluated using Delphi-based consensus success criteria as follows: healed wounds, no further infection interventions, and no PJI-related mortality.

RESULTS

In our study, 34.2% of the patients did not proceed with reimplantation due to reinfection or ongoing infection, which was influenced by factors such as high Charlson Comorbidity Index scores, recurrence of a microorganism, and shorter intervals between initial arthroplasty and reinfection. Among the reimplanted patients, 44.0% underwent further revision for rereinfection. Kaplan-Meier analysis of 1,119 initial, 75 repeat, and 24 re-repeat two-stage cases revealed 5-year infection-free survival rates of 93, 72, and 43%, respectively. This study identified significant reinfection risks in patients who have repeated infections by the same microorganisms, persistent PJI, or multiple spacer redo procedures. A 39.5% rereinfection rate, including 12 amputations and a 15.8% mortality rate, was observed in this series.

CONCLUSIONS

This study underscores the effectiveness of first-time two-stage EA for knee PJI and notes the challenges and lower success rates of subsequent attempts. This emphasizes the importance of identifying high-risk patients for tailored treatment plans and setting realistic expectations of outcomes.

LEVEL OF EVIDENCE

III.

Shoulder Periprosthetic Joint Infection: Principles of Prevention, Diagnosis, and Treatment

➢ Shoulder periprosthetic joint infection (PJI) is a potentially devastating complication after arthroplasty and is projected to rise with increasing numbers of performed arthroplasties, particularly reverse shoulder arthroplasties.➢ Important considerations for the diagnosis and treatment of shoulder PJI include age, sex, implant type, primary compared with revision shoulder surgery, comorbidities, and medications (i.e., corticosteroids and disease-modifying antirheumatic drugs). ➢ Diagnosis and management are unique compared with lower-extremity PJI due to the role of lower-virulence organisms in shoulder PJI, specifically Cutibacterium acnes.➢ Treatment pathways depend on chronicity of infection, culture data, and implant type, and exist on a spectrum from irrigation and debridement to multistage revision with temporary antibiotic spacer placement followed by definitive revision arthroplasty.

The role of acetabular cement augmentation in 2-stage revision arthroplasty for prosthetic joint infection of the hip

INTRODUCTION

In the treatment of chronic prosthetic joint infection (PJI) of the hip, two-stage exchange arthroplasty is commonly employed. Various spacer designs, including Hemi-Spacers and Articulating Spacers, are utilized during this process. However, these spacers are associated with a high rate of mechanical complications and pose a risk of progressive bone loss. This study aims to compare these two types of spacers in terms of mechanical complications, center of rotation (COR) restoration, and preservation of acetabular bone stock.

MATERIALS AND METHODS

From 2019 to 2022, patients who underwent two-stage exchange arthroplasty for hip PJI across three hospitals were retrospectively reviewed. Data including demographic, clinical, and microbiological information were collected. Radiographic imaging was analyzed to measure acetabular bone erosion, COR, and periacetabular bone resected. Additionally, the average surgical time in the first and second stages, mechanical complications, and the mean duration of the inter-stage period were recorded.

RESULTS

Forty patients were divided into two groups: Group A (Articulating Spacer, n = 23) received a preformed femur spacer with acetabular cement augmentation, while Group B (Hemi-Spacer, n = 17) received a preformed femur spacer alone. Acetabular cement augmentation slightly prolonged the first stage but facilitated a faster second stage during subsequent reimplantation. Spacer dislocation rates were 8.7% in Group A and 17.6% in Group B during the interstage period. Radiographic analysis revealed a statistically significant greater degree of acetabular erosion in Group B. A significant difference in Vertical-COR differential was observed, with a more proximalized revision cup compared to the primary cup in Group B, and Horizontal-COR values closer to the native hip in Group A.

CONCLUSIONS

Dynamic spacers with acetabular cement augmentation help preserve peri-acetabular bone stock and prevent progression of acetabular bone erosion during the inter-stage period. Additionally, these spacers reduce the dislocation rates, making reimplantation easier and leading to better restoration of hip biomechanics during the second procedure.

Regional Periprosthetic Joint Infection Centers: The Time Has Come for a Paradigm Change in the Treatment of Periprosthetic Joint Infection

BACKGROUND

Periprosthetic joint infection (PJI) is a rare, yet devastating complication with high mortality rates, unpredictable treatment outcomes, and high costs. The purpose of this study was to determine 90-day and 1-year mortality rates at a specialized PJI center, assess the impact of delayed referral to a PJI center on outcomes, and determine the cost of PJI treatment prior to referral to a PJI center.

METHODS

A review of our institution's PJI registry was performed to identify patients who had a chronic PJI treated with a 2-stage exchange arthroplasty at our PJI Center from 2017 to 2021. Patients not referred from an external location were excluded. Mortality at 90 days and 1 year was collected. The date of infection diagnosis until the date of referral was recorded. Outcomes were documented as failure of treatment at the final clinical follow-up. The number and type of prior infection treatments were documented for each patient. The estimated cost was calculated using established PJI literature.

RESULTS

There were 172 patients (182 joints) who met inclusion criteria during this timeframe. The 90-day and 1-year mortality rates were 0 and 3.9%, respectively. There was a higher failure rate in patients referred >90 days after the diagnosis of chronic PJI (23 versus 11%, P = 0.031). The total cost of PJI treatment prior to referral for this group of patients was $6.9 million.

CONCLUSIONS

Implementation of a specialized PJI referral center leads to lower mortality rates, improved outcomes, and decreased cost for the health-care system.

Treatment experience with continuous local antibiotic perfusion for periprosthetic joint infection

BACKGROUND

Antibiotic concentrations 100-1000 times higher than the minimum inhibitory concentration are necessary for eradicating biofilms in periprosthetic joint infections (PJI). Achieving this with intravenous antibiotics is challenging, but continuous local antibiotic perfusion (CLAP) can increase the local concentration of antibiotics. Although there are several reports on CLAP therapy in the fracture-related infection, there are only few reports on its application in PJI. Here, we report our experience with CLAP therapy for PJI.

METHODS

Eight patients with PJI (two males and six females, with mean age of 73.5 years [±11.6]) were treated at our department, and their clinical characteristics were analyzed. The parameters considered were the classification of PJI, surgical procedure, duration of CLAP, duration of transvenous antibiotic administration, time of CRP-negative status, whether the infection resolved or recurred, and whether there were complications due to CLAP.

RESULTS

Initial surgery included total knee arthroplasty in five cases, unicompartmental knee arthroplasty in one case, and total hip arthroplasty in two cases. There were four cases of early postoperative infection, two of acute delayed infection, and two of chronic delayed infection. The surgical procedures performed were two-stage revision for two patients, and debridement, antibiotics, and implant retention (DAIR) for the other six. The mean durations of CLAP and transvenous antibiotic administration were 8.5 (±2.4) and 22.4 days (±13.7), respectively, and the mean time to CRP-negative status was 23.3 days (±10.7). All eight patients successfully resolved without additional irrigation or debridement, and no recurrence was observed at the last follow-up after discontinuation of oral antibiotics. No systemic side effects of gentamicin or other complications associated with CLAP were observed.

CONCLUSION

All patients achieved infection resolution with the combined use of CLAP. This suggests that CLAP is a useful treatment option for PJI.

Long-term oritavancin therapy for shoulder prosthetic joint infection: A case guided by therapeutic drug monitoring (TDM)

Oritavancin is a novel long-acting lipoglycopeptide with in vitro activity against methicillin-resistant (MR) Gram-positive pathogens and a good bactericidal activity even in presence of biofilm forming bacteria. It has been approved for acute bacterial skin and skin structure infections (ABSSSI), but recent reports have demonstrated possible off-label uses, as for prosthetic joint infections (PJI), which, in more than half of cases, are caused by MR Gram positive organisms. We reported a case of a man in his eighties with a late shoulder PJI caused by methicillin resistant Staphyloccus epidermidis (MRSE) with contraindications for surgical replacement and few oral therapeutic options for a long term suppressive antibiotic therapy. The prosthesis was retained, and the patient received ten outpatient sequential doses of 1200 mg of oritavancin for 28 weeks, based on therapeutic drug monitoring (TDM) as a guide for correct timing of administration of each dose. During oritavancin administration, the patient achieved clinical cure, with disappearance of the pain and regaining pre-infection joint mobility, with no side effects reported and no further surgery or hospitalization needed. The treatment is ongoing as a long-lasting suppressive antimicrobial therapy. Oritavancin could represent an excellent solution for treating PJI caused by MR organism, especially in patients who need a long-term suppressive therapy.

The role of advanced metal artifact reduction MRI in the diagnosis of periprosthetic joint infection

Identification and diagnosis of periprosthetic joint infection (PJI) are challenging, requiring a multi-disciplinary approach involving clinical evaluation, laboratory tests, and imaging studies. MRI is advantageous to alternative imaging techniques due to superior soft tissue contrast and absence of ionizing radiation. However, the presence of metallic implants can cause signal loss and artifacts. Metal artifact suppression (MARS) MRI techniques have been developed that mitigate metal artifacts and improve periprosthetic soft tissue visualization. This paper provides a review of the various MARS MRI techniques, their clinical applicability and accuracy in PJI diagnosis and evaluation, and current challenges and future perspectives.

Survivorship and Outcomes of 2-Stage Revision for Infected Total Hip Arthroplasty at a Mean of 7-Year Follow-Up

BACKGROUND

Periprosthetic joint infection (PJI) continues to be one of the leading causes of failure following total hip arthroplasty (THA). The objectives of the study were to (1) determine the minimum 2-year infection-free survivorship of 2-stage revision THA, (2) determine the causative organisms for repeat 2-stage revision THA, and (3) characterize the results of failed 2-stage revisions and evaluate patient-reported outcome measures (PROMs).

METHODS

A retrospective chart review was completed for patients who underwent 2-stage revision THA for PJI. Prospective data were collected on each patient, including demographics, causative organisms, complications, and type of reoperation. The PROMs, including Harris Hip Score, 12-item Short-Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained prior to 2-stage revision THA surgery and annually as part of standard clinical and radiographic follow-up.

RESULTS

A total of 328 patients who underwent a 2-stage revision THA for a PJI were included in the study (mean age 67 years [range, 28 to 90], mean body mass index of 30.6 [range, 15 to 57]). The overall infection-free survivorship for 2-stage revision THA was 73.8% at a minimum of 2 years (range, 2 to 20). Overall, 194 (59.1%) patients who had successful infection eradication underwent a 2-revision THA only. The most common single organisms infected were Staphylococcus aureus (12.5%) and Staphylococcus epidermidis (11%). Higher reoperation rates were found in cases with methicillin-resistant Staphylococcus aureus and polymicrobial infections. All PROMs showed statistical improvement from preoperatively to the latest follow-up appointment.

CONCLUSIONS

Two-stage revision THA is associated with a good success rate in the treatment of PJIs at mid-term to long-term follow-up. Polymicrobial and methicillin-resistant Staphylococcus aureus infections are poor prognostic factors, making the eradication of infection more difficult. The management of PJIs continues to be one of the most important orthopaedic challenges to treat.

Patient-Related Predictors of Treatment Failure After Two-Stage Total Hip Arthroplasty Revision for Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

BACKGROUND

Periprosthetic joint infection (PJI) treatment has high failure rates even after 2-stage revision. Risk factors for treatment failure (TF) after staged revision for PJI are not well defined, nor is it well established how they correlate with the risks of developing an index PJI. Identifying modifiable risk factors may allow preoperative optimization, while identifying nonmodifiable risk factors can influence surgical options or advise against further surgery. We performed a systematic review and meta-analysis to better define predictors of TF in 2-stage revision for PJI.

METHODS

The PubMed, Embase, and Scopus databases were searched from their inception in December 1976 to April 15, 2023. Studies comparing patient-related variables between patients successfully treated who had 2-staged revision total hip arthroplasty (THA) and patients with persistent infections were included. Studies were screened, and 2 independent reviewers extracted data, while a third resolved discrepancies. Meta-analysis was performed on these data. There were 10,052 unique studies screened, and 21 studies met the inclusion criteria for data extraction.

RESULTS

There was good-quality evidence that obesity, liver cirrhosis, and previous failed revisions for PJI are nonmodifiable risk factors, while intravenous drug use (IVDU) and smoking are modifiable risk factors for TF after 2-stage revision for hip PJI. Reoperation between revision stages was also significantly associated with an increased risk of TF. Interestingly, other risk factors for an index PJI including male gender, American Society of Anesthesiology score, diabetes mellitus, and inflammatory arthropathy did not predict TF. Evidence on Charlson Comorbidity Index was limited.

CONCLUSIONS

Patients with a smoking history, obesity, IVDU, previous failed revision for PJI, reoperation between stages, and liver cirrhosis are more likely to experience TF after 2-stage revision THA for PJI. Modifiable risk factors include smoking and IVDU and these patients should be referred to services for cessation as early as possible before 2-stage revision THA.

Diagnostic and Predictive Efficacy of Synovial Fluid Versus Serum C-Reactive Protein Levels for Periprosthetic Joint Infection and Reimplantation Success

BACKGROUND

A 2-stage exchange revision for periprosthetic joint infection (PJI) is associated with major risks for reinfection. Although serum markers are frequently used for diagnosis, their effectiveness remains debatable. Synovial fluid markers may offer a more accurate diagnosis of PJI; however, the importance of these biomarkers, notably synovial fluid C-reactive protein (syCRP), remains controversial, particularly in the context of reimplantation. The present study aimed to clarify these diagnostic uncertainties by evaluating the diagnostic efficacy of syCRP versus serum CRP (seCRP) levels in the context of PJI and recurring or persisting infections before reimplantation.

METHODS

A total of 186 patients were enrolled and divided into 2 groups: aseptic revision (n = 112) and PJI revision (n = 74). Of the PJI group, 65 were categorized as success and 9 as failure, based on the presence of recurrent or persistent infection before reimplantation. The syCRP and seCRP levels and their changes were assessed preoperatively and in the first-stage and second-stage revisions. Additionally, receiver operating characteristic (ROC) curves and area under the ROC curves (AUCs) were analyzed.

RESULTS

Both seCRP and syCRP levels were significantly elevated in the PJI group compared with the aseptic group (P < .001). The ROC curve analysis highlighted the enhanced diagnostic accuracy of syCRP for PJI, with an AUC of 0.93 versus 0.80 for seCRP. Furthermore, syCRP proved to be more reliable in predicting reimplantation success, exhibiting an AUC of 0.86 versus 0.63 for seCRP. In evaluating trends in CRP levels to determine reimplantation timing, changes in syCRP levels demonstrated superior diagnostic utility, exhibiting an AUC of 0.79 versus 0.63 for changes in seCRP levels.

CONCLUSIONS

In assessing PJI and infections before reimplantation, syCRP may offer enhanced accuracy compared with seCRP. Nevertheless, variations in both syCRP and seCRP levels did not consistently predict the outcome of reimplantation.

Zirconium as a Promising Synovial Biomarker for Loose Cemented Knee Prosthesis

BACKGROUND

Aseptic loosening is the most common mode of failure after total knee arthroplasty. Despite this, the diagnosis often remains challenging and mainly relies on imaging modalities. Until today, no biomarker exists to aid in diagnosing loosening of the implants. As zirconium (Zr) is often found in bone cement, where it serves as radiopacifier, this study aimed to establish Zr as a synovial biomarker for loosened cemented knee prostheses.

METHODS

A total of 31 patients scheduled for revision of a cemented knee prostheses were included. In all patients, the initial used cement contained Zr. After arthrotomy, specimens of synovial fluid were taken and levels of Zr were measured by inductively coupled plasma mass spectrometry. Depending on the necessary amount of force for explantation, the implants were graded "loose" or "well-fixed". Preoperative radiographs were evaluated by 2 independent physicians.

RESULTS

The concentration of Zr in the synovial fluid differed significantly (P < .001) between the "loose" (mean 170.9 μg/L, range 0 to 1941 μg/L) and the "well-fixed" (mean 0.6 μg/L, range 0 to 6 μg/L) implants. The receiver operating characteristic analysis revealed 0.25 μg/l as an optimal cutoff value leading to a sensitivity of 0.84, a specificity of 0.92, a positive predictive value of 0.94, and a negative predictive value of 0.79. There was no significant difference in the diagnostic performance compared to radiographs (P = .66).

CONCLUSIONS

Zirconium proved to be a reliable novel synovial biomarker for diagnosing aseptic loosening of knee prothesis fixed with cement containing Zr. This biomarker should not be interpreted in isolation, but in combination with existing diagnostic tools.

Pasteurella multocida From a Cat Scratch as a Cause of Recurrent Prosthetic Joint Infection After Previously Successful Single-Stage Exchange Arthroplasty

We report a case of a 74-year-old female with a history of a prosthetic joint infection that was successfully treated with a single-stage exchange arthroplasty, off antibiotics, and without symptoms for 20 months. She presented 1 week after a cat scratch with acute knee pain, and aspiration grew Pasteurella multocida. She was successfully treated with surgical debridement and a prolonged course of antibiotics. Debate remains in the literature regarding whether recurrent infections represent a previously undetected organism or a new infection. Our report provides convincing evidence that, at least in some circumstances, the infection is new. Furthermore, this is the first case described of P. multocida resulting in a recurrent prosthetic joint infection after a previously successful exchange arthroplasty due to a different causative organism.

The influence of gut microbiome on periprosthetic joint infections: State-of-the art

Early periprosthetic joint infection constitutes one of the most frightening complications of joint replacement. Recently, some evidence has highlighted the potential link between dysregulation of the gut microbiota and degenerative diseases of joints. It has been hypothesized that microbiome dysbiosis may increase the risk of periprosthetic joint infection by facilitating bacterial translocation from these sites to the bloodstream or by impairing local or systemic immune responses. Although the processes tying the gut microbiome to infection susceptibility are still unknown, new research suggests that the presurgical gut microbiota-a previously unconsidered component-may influence the patient's ability to resist infection. Exploring the potential impact of the microbiome on periprosthetic joint infections may therefore bring new insights into the pathogenesis and therapy of these disorders. For a successful therapy, a proper surgical procedure in conjunction with an antibacterial concept is essential. As per the surgical approach, different treatment strategies include surgical irrigation, debridement, antibiotic therapy, and implant retention with or without polyethylene exchange. Other alternatives could be one-stage or two-stage revisions surgery. Interventions that either directly target gut microbes as well as interventions that modify the composition and/or function of the commensal microbes represent an innovative and potentially successful field to be explored. In recent times, innovative therapeutic methods have arisen in the realm of microbiome restoration and the management of gut-related ailments. These progressive approaches offer fresh perspectives on tackling intricate microbial imbalances in the gastrointestinal tract. These emerging therapies signify a shift towards more precise and individualized approaches to microbiome restoration and the management of gut-related disorders. Once a more advanced knowledge of the pathways linking the gut microbiota to musculoskeletal tissues is gained, relevant microbiome-based therapies can be developed. If dysbiosis is proven to be a significant contributor, developing treatments for dysbiosis may represent a new frontier in the prevention of periprosthetic joint infections.

Improved cure rate of periprosthetic joint infection through targeted antibiotic therapy based on integrated pathogen diagnosis strategy

Objectives

This study aimed to determine whether combined of pathogen detection strategies, including specimen acquisition, culture conditions, and molecular diagnostics, can improve treatment outcomes in patients with periprosthetic joint infections (PJI).

Methods

This retrospective study included suspected PJI cases from three sequential stages at our institution: Stage A (July 2012 to June 2015), Stage B (July 2015 to June 2018), and Stage C (July 2018 to June 2021). Cases were categorized into PJI and aseptic failure (AF) groups based on European Bone and Joint Infection Society (EBJIS) criteria. Utilization of pathogen diagnostic strategies, pathogen detection rates, targeted antibiotic prescription rates, and treatment outcomes were analyzed and compared across the three stages.

Results

A total of 165 PJI cases and 38 AF cases were included in this study. With the progressive implementation of the three optimization approaches across stages A, B and C, pathogen detection rates exhibited a gradual increase (χ2 = 8.282, P=0.016). Similarly, utilization of targeted antibiotic therapy increased stepwise from 57.1% in Stage A, to 82.3% in Stage B, and to 84% in Stage C (χ2 = 9.515, P=0.009). The 2-year infection control rate exceeded 90% in both stages B and C, surpassing stage A (71.4%) (χ2 = 8.317, P=0.011). Combined application of all three optimized protocols yielded the highest sensitivity of 91.21% for pathogen detection, while retaining higher specificity of 92.11%.

Conclusion

The utilization of combined pathogen diagnostic strategies in PJI can increase pathogen detection rates, improve targeted antibiotic prescription, reduce the occurrence of antibiotic complications, and achieve better treatment outcomes.

Transcutaneous compression suture with iodine gauze for wound closure in revision surgery for therapy-resistant periprosthetic shoulder infections

Background

To successfully treat a periprosthetic infection, successful bacteria eradication and successful wound closure are mandatory. Despite adequate surgical débridement in the deep, persistence of wound drainage and subsequent persistence of periprosthetic infection may occur, especially in patients with compromised soft tissue conditions. This study presents a transcutaneous compression suture technique with iodine gauze that was used in patients with persistent wound secretion in therapy-resistant periprosthetic shoulder infections in order to achieve successful infection control and wound healing.

Methods

All patients with persistent periprosthetic or implant-associated shoulder joint infections despite correct previous surgical and antibiotic therapy attempts were included in the study. In all patients, in addition to repeat deep surgical débridement, a transcutaneous "iodine-gauze-compression-suture" was performed with postoperative antibiotic therapy. The primary endpoint was infection control; the secondary endpoint was wound healing rate; and the third endpoint was complication rate after index surgery.

Results

Ten consecutive patients with a mean age of 74 (±7.6) years and a mean follow-up of 14 (±2) months were included. All ten patients showed infection control and successful wound healing, with no need for further revision surgery. In 8 out of 10 patients, the wound healing was fast and completely uncomplicated. Two out of 10 patients showed delayed wound healing with fibrin coatings for 3 and 4 weeks, respectively. No additional intervention was necessary in both patients.

Conclusions

Transcutaneous iodine gauze compression sutures were used to achieve successful infection control without additional revision surgery in 10 out of 10 patients who previously underwent surgery with failed infection control. This wound closure technique is a reliable adjunctive therapy method in the treatment of implant-associated infections of the shoulder in patients with fragile wound conditions.

Concomitant malnutrition and frailty are significant risk factors for poor outcome following two-stage revision for chronic periprosthetic joint infection

BACKGROUND

Two-stage revision remains the gold standard for periprosthetic joint infection (PJI) treatment. Although previous studies have examined malnutrition and frailty independently, their cumulative effects are not clear. Therefore, this study aimed to assess the individual and combined influence of malnutrition and frailty on the two-stage revision surgery.

METHODS

Patients with chronic PJI undergoing two-stage revision were retrospectively included. The definition of PJI is completely consistent with the evidence-based definition of PJI recorded by the MSIS in 2018. Preoperative serum albumin levels and 11-item modified frailty index scores were collected. Four cohorts were created: (1) Normal (N), (2) Frail (F), (3) Malnourished (M), and (4) Malnourished and frail (MF). Demographic data, comorbidities, and postoperative complications were collected and compared between the four cohorts.

RESULTS

A total of 117 consecutive patients were enrolled, 48% of patients were healthy (27.4% F, 16.2% M, and 9.4% MF). MF group showed lower scores on the physical composite scale of the 12-item short-form health survey (SF12-PCS), mental composite summary (SF12-MCS), Harris hip score (HHS), and knee society score (KSS) (P < 0.05). The incidence of reinfection in the MF group was higher than that in all other groups (MF vs. N; odds ratio [OR] 3.7, 95% confidence interval [CI] 1.37 - 8.82, P = 0.032). The incidence of complications in the MF group was higher than that in all other groups (MF vs. N; OR 4.81, 95% CI 1.58-9.26, P = 0.018). Postoperative transfusion events (OR 2.92, 95% CI 1.27-3.09, P = 0.021), readmission at 60 days after the operation (OR 4.91, 95% CI 1.82-13.80, P = 0.012) was higher in the MF patients. In addition, the extended length of stay after the operation was highest in the MF patients, with an OR of 5.78 (95% CI 2.16-12.04, P = 0.003).

CONCLUSION

The concurrent presence of concomitant malnutrition and frailty in patients with PJI is related to poor prognosis and may be a predictor of the efficacy of two-stage revision. Future research will be needed to describe the benefits of improving these risk factors for patients with PJI.

The Influence of Patient Sex on Outcomes Following One-Stage and Two-Stage Revision for Periprosthetic Joint Infection in Total Joint Arthroplasty

Although females have a higher rate of primary total joint arthroplasty (TJA), males have a higher rate of revision. The literature lacks studies examining the relationship between sex and outcomes following single and two-stage exchange for periprosthetic joint infection (PJI). The purpose of this study was to examine if differences exist in outcomes following revision for chronic PJI between sexes. A retrospective review was performed on all patients with an MSIS confirmed PJI who underwent a single or two-stage exchange at our institution from January 2010 to January 2021. Patient demographics, comorbidity characteristics, and outcomes were collected and compared between males and females. The primary outcome variable was disease-free survival at 1 year following definitive revision. Multivariable logistic regression analysis was performed to determine risk factors for failure. Of the 470 patients meeting final eligibility criteria, 250 were male and 226 were female (2 males and 4 females had a joint infection of either the contralateral side or a different joint and were treated as separate records). Of the patients in the cohort, 80% of the males (200/250) and 80% of the females (181/226) were found to be disease-free at 1-year follow-up (p > 0.99). Multivariable logistic regression analysis showed that nicotine use and diabetes, but not sex, were significant predictors of failure. Our study did not find a relationship between sex and outcome of revision for PJI. Further research is required to determine whether differences exist between males and females in the expression of PJI and outcomes following treatment.

Current relevance of biomarkers in diagnosis of periprosthetic joint infection: an update

With a significant rise in the number of arthroplasty procedures performed worldwide, the increasing revision burden posed by periprosthetic joint infection (PJI) is a matter of growing concern. In spite of various attempts to diagnose PJI, there are no defined tests that can be called a gold standard. Given the importance of early diagnosis in PJI, newer tests and biomarkers have been introduced to improve cumulative diagnostic accuracy. Novel biomarkers like calprotectin, lipocalcin, monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and platelet-to-mean platelet volume ratio have demonstrated a potential as diagnostic biomarkers for PJI. This article discusses the relevance of available and newly described diagnostic biomarkers to provide a perspective on the practical applicability in current medical practice, as well as highlights some recent advances in biomarkers for the diagnosis of PJI.

HMGB-1 Levels in Painful Knee Arthroplasty: Is it Possible to Distingue Periprosthetic Joint Infection and Aseptic Loosening?

Introduction

We investigated the efficiency of high mobility group box-1 protein (HMGB-1) in differentiation of asymptomatic knee prosthesis, and periprosthetic joint infection and aseptic loosening causing painful knee prosthesis.

Materials and Methods

The data of patients who consulted our clinic for checking after total knee arthroplasty surgery were recorded prospectively. Blood levels of CRP, ESR, WBC, and HMGB-1 were recorded. Patients whose examination and routine tests were within normal limits comprised group I, asymptomatic total knee arthroplasty (ATKA). Painful patients with abnormal test results underwent three phase bone scintigraphy for further investigation Patients with periprosthetic joint infection (PJI) and aseptic loosening (AL) according to scintigraphy comprised group II and group III, respectively. The mean values of HMGB-1 and cut-off values according to the groups and their correlations with other inflammatory parameters were determined.

Results

Seventy-three patients were included in the study. Significant differences were observed in three groups, in terms of CRP, ESR, WBC, and HMGB-1. The cut-off value of HMGB-1 was determined as 15.16 ng/ml between ATKA and PJI, 16.92 ng/ml between ATKA and AL, and 27.87 ng/ml between PJI and AL, respectively. Accordingly, the sensitivity, and specificity of HMGB-1 in differentiation of ATKA and PJI were 91%, 88%, and in differentiation of ATKA and AL were 91%, 96%, and in differentiation of PJI and AL were 81%, 73%, respectively.

Conclusion

HMGB-1 may be utilized as an additional blood test in the differential diagnosis of problematic knee prosthesis patients.

Hypoalbuminemia Predicts Failure of Two-Stage Exchange for Chronic Periprosthetic Joint Infection of the Hip and Knee

BACKGROUND

Nutritionally compromized patients, with preoperative serum albumin (SAB) < 3.5g/dL, are at higher risk for periprosthetic joint infection (PJI) in total joint arthroplasty. The relationship between nutritional and PJI treatment success is unknown. The purpose of this study was to examine the relationship between preresection nutrition and success after first-stage resection in planned two-stage exchange for PJI.

METHODS

A retrospective review was performed on 418 patients who had first-stage resection of a planned two-stage exchange for chronic hip or knee PJI between 2014 and 2018. A total of 157 patients (58 hips and 99 knees) were included who completed first stage, had available preop SAB and had a 2-year follow-up. Failure was defined as persistent infection or repeat surgery for infection after resection. Demographic and surgical data were abstracted and analyzed.

RESULTS

Among knee patients with preop SAB >3.5 g/dL, the failure rate was 32% (15 of 47) versus a 48% (25 of 40) failure rate when SAB <3.5 g/dL (P = .10). Similarly, the failure rate among hip patients with preop SAB >3.5 g/dL versus 12.5% (3 of 24) versus 44% (15 of 34) for hip patients with SAB <3.5 g/dL (P = .01). Multivariable regression results indicated that patients with SAB< 3.5 g/dL (P = .0143) and Musculoskeletal Infection Society host type C (P = .0316) were at an increased risk of failure.

CONCLUSION

Low preoperative SAB and Musculoskeletal Infection Societyhost type-C are independent risk factors for failure following first-stage resection in planned two-stage exchange for PJI. Efforts to nutritionally optimize PJI patients, when possible, may improve the outcome of two-stage exchange.

The role of sonication in the diagnosis of periprosthetic joint infection in total shoulder arthroplasty

An increased sensitivity of sonication compared to periprosthetic tissue cultures in the diagnosis of periprosthetic joint infection (PJI) of hip and knee arthroplasty has been reported. The goal of this study was to determine if there is also an added value of implant sonication in the diagnosis of PJI in total shoulder arthroplasty (TSA). A retrospective analysis of patients who underwent removal of their TSA combined with sonication of the implant for suspicion of PJI between April 2009 and August 2017 was performed. The diagnosis of PJI was based on the major criteria described by Parvizi. We calculated sensitivity, specificity, predictive values, likelihood ratios and diagnostic accuracy for sonication cultures in comparison with periprosthetic tissue cultures. Data from 41 patients were analysed. Standard synovial fluid cultures combined with intraoperative periprosthetic tissue cultures had a sensitivity of 95%, specificity of 95% and total accuracy of 95%. Sonication cultures had a sensitivity of 91%, specificity of 68% and total accuracy of 80%. Six patients had negative standard cultures but positive sonication cultures. In patients with only one positive standard culture, the pathogen of the sonication culture corresponded to the pathogen of the positive soft tissue culture. We found a possible added value of sonication of TSA in the diagnosis of PJI in conjunction with standard intraoperative cultures. In some patients with suspicion of low-grade TSA infection, sonication could identify a possible causal microorganism despite negative standard cultures.

Diagnostic accuracy of sonication fluid cultures from prosthetic components in periprosthetic joint infection: an updated diagnostic meta-analysis

BACKGROUND

Periprosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty (TJA) and has a significant impact on patients and the national healthcare system. To date, the diagnosis of PJI is still confronted with dilemmas. The present study investigated the validity of sonication fluid culture (SFC) for removing implants in the diagnosis of PJI after joint replacement.

METHODS

From database establishment to December 2020, relevant literature was retrieved from the PubMed, Web of Science, Embase and Cochrane Library databases. Two reviewers independently performed quality assessment and data extraction to calculate the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), area under the curve (AUC) and diagnostic odds ratio (DOR) to evaluate the diagnostic value of overall SFC for PJI.

RESULTS

A total of 38 eligible studies including 6302 patients were selected in this study. The pooled sensitivity, specificity, PLR, NLR, and DOR of SFC for PJI diagnosis were 0.77 (95% confidence interval [CI], 0.76-0.79), 0.96 (95% CI, 0.95-0.96), 18.68 (95% CI, 11.92-29.28), 0.24 (95% CI, 0.21-0.29), and 85.65 (95% CI, 56.46-129.94), respectively, while the AUC was 0.92.

CONCLUSION

This meta-analysis showed that SFC was of great value in PJI diagnosis, and the evidence of SFC on PJI was more favorable but not yet strong. Therefore, improvement of the diagnostic accuracy of SFC is still necessary, and the diagnosis of PJI continues to warrant a multiplex approach before and during a revision procedure.

A Multicenter Prospective Investigation on Patient Physical and Mental Health After Girdlestone Resection Arthroplasty

BACKGROUND

Girdlestone resection arthroplasty is a salvage procedure for hip periprosthetic joint infection (PJI) that controls infection and reduces chronic pain, but may result in limited postoperative joint function. The aim of this study was to assess physical function and mental health after Girdlestone.

METHODS

This was a multicenter, prospective study evaluating patients with Girdlestone. The Prosthesis Evaluation Questionnaire (PEQ) and patient-reported outcomes measurement information system (PROMIS) global physical health and mental health surveys were administered postoperatively via telephone. The PEQ consists of four scales (ie, ambulation, frustration, perceived response, and social burden) with scores ranging from 0 to 10. The PROMIS measures generated T-scores (mean: 50, standard deviation: 10) that enable comparison to the general population.

RESULTS

Thirty-five patients completed all surveys. The average time from procedure to survey completion was 6 years (range, 1 to 20). The median scores for the ambulation, frustration, perceived response, and social burden scales of the PEQ were 0.0 [interquartile range: 0-4.1], 6.0 [3.0-9.3], 9.0 [7.2-10.0], and 7.5 [4.3-9.5]. The median raw scores of the PROMIS global physical health and mental health were 11.91 [interquartile range: 9-14] and 14.0 [10.0-16.0]. These corresponded to average T scores of 39.7 (standard error : 4.3) for physical health and 46.1 (standard error: 3.8) for mental health, which were 10.3 points and 3.9 points below the average score in the United States general population, respectively.

CONCLUSION

Girdlestone can have a substantial negative impact on physical functions; however, mental health and social interaction may be only moderately affected. These outcomes can be used to guide patient expectations, as this procedure may be necessary in certain salvage scenarios.

D-Dimer, Erythrocyte Sedimentation Rate, and C-Reactive Protein Sensitivities for Periprosthetic Joint Infection Diagnosis

BACKGROUND

There is contradicting evidence on the diagnostic value of inflammatory biomarkers for periprosthetic joint infection (PJI). We sought to quantify the sensitivity of D-dimer for acute and chronic PJI diagnosis and evaluate D-dimer lab values in the 90-day postoperative window in a control cohort of primary joint arthroplasty patients for comparison.

METHODS

An institutional database was queried for patients undergoing revision procedures for PJI after total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2014 to present. CRP, ESR, and D-dimer were collected within 90 days pre and postoperatively and sensitivities for the diagnosis of PJI were calculated. The control group included patients who underwent a negative diagnostic workup for deep venous thrombosis (DVT) or pulmonary embolus (PE) and had a D-dimer lab collected within 90 days postoperatively from primary total joint arthroplasty (TJA).

RESULTS

A total of 604 PJI patients were identified, and 81 patients had D-dimer, ESR, and CRP collected. There were 50/81 acute PJI patients and 31/81 chronic PJI patients who had median D-dimer values of 2,136.5 ng/mL [interquartile range (IQR): 1,642-3,966.5] and 3,336 ng/mL [IQR: 1,976-5,594]. Only the chronic PJI group had significantly higher D-dimer values when compared to the control cohort (P = .009). The sensitivity of D-dimer was calculated to be 92% and 93.5% in the acute and chronic PJI groups, respectively.

CONCLUSION

Serum D-dimer may not have high diagnostic utility for acute PJI, especially in the setting of recent surgery; however, it still may be useful for patients who have chronic PJI.

Next-Generation Sequencing Supports Targeted Antibiotic Treatment for Culture Negative Orthopedic Infections

The isolation of an infective pathogen can be challenging in some patients with active, clinically apparent infectious diseases. Despite efforts in the microbiology lab to improve the sensitivity of culture in orthopedic implant-associated infections, the clinically relevant information often falls short of expectations. The management of peri-prosthetic joint infections (PJI) provides an excellent example of the use and benefits of newer diagnostic technologies to supplement the often-inadequate yield of traditional culture methods as a substantial percentage of orthopedic infections are culture-negative. Next-generation sequencing (NGS) has the potential to improve upon this yield. Bringing molecular diagnostics into practice can provide critical information about the nature of the infective organisms and allow targeted therapy in these otherwise challenging situations. This review article describes the current state of knowledge related to the use and potential of NGS to diagnose infections, particularly in the setting of PJIs.

Symptom duration is associated with failure of periprosthetic joint infection treated with debridement, antibiotics and implant retention

Background

Debridement, antibiotics, and implant retention (DAIR) is an alternative treatment strategy for periprosthetic joint infection (PJI). However, no consensus exists regarding which patient population(s) may be most suitable for DAIR. This study aims to investigate the overall infection control rate and explore the prognostic factors associated with acute, hematogenous, and chronic PJIs treated with DAIR.

Methods

We retrospectively reviewed the included patients who were diagnosed with PJI and underwent DAIR at two institutions from 2009 to 2018 (n = 104). We collected the clinical data, including demographics, preoperative laboratory tests, Charlson Comorbidity Index, surgical information, and culture organism results. Treatment success was defined according to the criteria reported by Diaz-Ledezma. All patients were followed for at least one year unless failure preceded that time point. A multivariable analysis was utilized to identify prognostic factors associated with treatment, and a Kaplan-Meier survival analysis was used to depict the infection control rate.

Results

The overall treatment success rate in the current cohort of patients was 67.3% at a median 38.6 (interquartile range: 23.5, 90.7) months follow-up. Patients with a duration of infectious symptoms of more than ten days were more likely to fail (P = 0.035, hazard ratio 8.492, 95% confidence interval 1.159–62.212). There was no difference among acute, hematogenous, and chronic infections in terms of failure rate (P = 0.161).

Conclusions

DAIR is a reasonable treatment option for PJI, and its use in the setting of chronic infection does not appear to be a contraindication. Performing DAIR within ten days of the presentation of symptoms had a higher rate of treatment success.

Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty

BACKGROUND

While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA.

METHODS

This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections.

RESULTS

648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI.

DISCUSSION

A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.

High-Dose Antibiotic Cement Spacers Independently Increase the Risk of Acute Kidney Injury in Revision for Periprosthetic Joint Infection: A Prospective Randomized Controlled Clinical Trial

BACKGROUND

Standard treatment for periprosthetic joint infection (PJI) involves 2-stage exchange with placement of an antibiotic-impregnated cement spacer (ACS). Conflicting evidence exists on the role of ACS in development of acute kidney injury (AKI) after first-stage surgery. In this randomized clinical trial, we aimed to compare the incidence of AKI between the first-stage of a planned 2-stage exchange vs 1-stage exchange. This study design isolates the effect of the ACS in otherwise identical treatment groups.

METHODS

The primary outcome variable was AKI, defined as a creatinine ≥1.5 times baseline or an increase of ≥0.3 mg/dL. Risk factors for AKI were evaluated using bivariate statistical tests and multivariable logistic regression.

RESULTS

Patients who underwent the first stage of a planned 2-stage exchange were significantly more likely to develop AKI compared with the 1-stage exchange group (15 [22.7%] vs 4 [6.6%], P = .011). On multivariable regression analysis, ACS placement (odds ratio 7.48, 95% confidence limit 1.77-31.56) and chronic kidney disease (odds ratio 3.84, 95% confidence limit 1.22-12.08) were independent risk factors for AKI.

CONCLUSION

Our study provides evidence that high-dose antibiotic cement spacers for treatment of PJI are an independent risk factor for AKI. Therefore, efforts to minimize nephrotoxicity should be employed in revision for PJI when possible.

Staged revision still works for chronic and deep infection of total elbow arthroplasty?

Purpose: Infected total elbow arthroplasty (TEA) is challenging. We evaluate the clinical and radiologic outcomes for chronic and deep infection of TEA with two-stage revision surgery. Methods: A total of 10 elbows were included in the study. The mean age was 69.1 ± 15 years (range, 34–83 years). The mean follow-up was 62 (range, 24–108) months. The clinical outcomes were assessed using a visual analog scale (VAS), range of motion (ROM) arc, and Mayo elbow performance score (MEPS). Moreover, radiographic outcomes, time to revision, pathogenic bacteria, preoperative complications, and disease period were evaluated. Results: Mean preoperative VAS score of 6.1 had improved to 3.3. Mean preoperative ROM was 68° (flexion-extension), which improved to 86.7°. Mean preoperative MEPS was 46 (range, 0–70), which improved to 75.5 (range, 35–85). The mean disease duration was 8.4 months (range, 5–20 months). The most common causative organism was methicillin-resistant Staphylococcus aureus. The second revision rate was 80% at the final follow-up. Radiographic outcome at final follow-up showed that 3 (30%) of 10 patients exhibited radiolucency evidence around the components. Three patients showed nonprogressive radiolucency around the implant interfaces without other indications of infection at the most recent follow-up. Conclusion: In patients with chronic and deep infection of TEA, two-stage revision can be an affordable option for eradication of the infection, relieving pain, and restoring joint function. However, the high second revision rate owing to bone and soft-tissue deficits remains a critical issue.

Level of evidence: Level IV, Case series, Treatment study

Outcomes of Primary Total Knee Arthroplasty in Fractures Around the Knee in the Elderly: A Systematic Review and Pooled Analysis of 212 Patients Across 11 Studies

BACKGROUND

Treatment of fractures around the knee in the elderly is somewhat controversial with primary total knee arthroplasty (TKA) gaining prominence over the past decade or so, as an alternative for open reduction and internal fixation. The present review was conceptualized to review the published literature and evaluate outcomes of TKA in these patients, and to understand whether this is a viable treatment option for these fractures. We have further tried to identify complications and the challenges faced while performing this surgery.

METHODS

PRISMA guidelines were followed and search was conducted on three databases-PubMed, EMBASE and SCOPUS. Studies evaluating multiple factors related to outcomes and complications in primary TKA performed for fractures around the knee in the elderly were included. Cadaveric studies, conference abstracts, case reports, and any studies that included non-traumatic cases or revision after failed internal fixation, were all excluded.

RESULTS

Eleven studies, published between 2011 and 2021 were included in our review. There was significant female preponderance in the study population (M:F = 1:3). Implants with higher constraint (high post, hinged prosthesis) were frequently required to compensate for ligamentous laxity due to the fractures. On pooled analysis the mean Knee Society Score (KSS) knee score was 84.62 (excellent), and mean knee range of motion was 107.25°. However, the mean KSS function score was 56.71 (poor), which could have been due to co-morbid conditions and pre-operative status. Overall complication rate was 14.6%; surgical site infection was the most commonly reported.

CONCLUSION

There remains limited evidence for the use of TKA as a primary treatment option for these injuries. In the presence of specific conditions, and in expert hands-it may be a viable alternative to osteosynthesis with comparable outcomes. More focused studies are needed to compare the two treatment options and to formulate guidelines.

The accuracy of D-dimer in the diagnosis of periprosthetic infections: a systematic review and meta-analysis

Background

Periprosthetic joint infection (PJI) is a devastating complication after total hip arthroplasty (THA) or total knee arthroplasty (TKA). It is scarce and contradicting evidence supporting the use of serum D-dimer to diagnose PJI in revision THA and TKA. This systematic review and meta-analysis aimed to investigate the accuracy of D-dimer in the diagnosis of periprosthetic infections.

Methods

The PubMed, Embase, Web of Science were systematically searched from the inception dates to August 15, 2020. We included all diagnostic studies of D-dimer in the diagnosis of periprosthetic infections. The literature's quality was evaluated by the QUADAS-2 tool, and Stata16 and Revman5.3 software carried out the meta-analysis.

Results

Of 115 citations identified by the search strategy, 10 studies (comprising 1756 participants) met the inclusion criteria. The literature quality assessment results show that most of the literature is low-risk bias literature. The combined sensitivity of D-dimer in diagnosing periprosthetic infections was 0.81 (95% confidence interval [CI] 0.71–0.88), combined specificity was 0.74 (95% CI 0.61–0.84), combined positive likelihood ratio was 3.1 (95% CI 2.0–5.0), combined negative likelihood ratio 0.26 (95% CI 0.16–0.41), combined diagnosis odds ratio 12 (95% CI 5–27), area under the Summary Receiver Operator Characteristic Curve (SROC) is 0.85 (95% CI 0.81–0.88). The data are statistically significant.

Conclusion

D-dimer has a high diagnostic value in diagnosing PJI and has clinical significance in diagnosing periprosthetic infection. In addition, there are relatively few studies on the threshold of D-dimer, different sampling types, different laboratory detection methods, and different races, so more prospective trials with large samples, multi-centers, and scientific design should be carried out in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03001-y.

An Insight Into Lyme Prosthetic Joint Infection in Knee Arthroplasty: A Literature Review

Lyme prosthetic joint infection (PJI) is a rare event, but it is imperative to include Lyme disease as a possible cause of PJI in a Lyme-endemic region. The purpose of this article was to review the reported cases of Lyme PJIs in knee arthroplasty and to initiate the development of a treatment strategy. We found five cases of Lyme PJI in the literature. All patients lived in the northeastern region of the United States. Four patients were successfully treated with surgical intervention and postoperative antibiotics. One patient was successfully treated with intravenous and oral antibiotics for 6 weeks, without surgical intervention. Synovial fluid Lyme polymerase chain reaction and serological tests were positive in all patients. On follow-up visits, after completion of their treatment, all patients were asymptomatic with a painless functional knee. We recommend considering Lyme disease as a cause of culture-negative PJIs in endemic regions. Additional research is needed to clearly define a treatment algorithm. Based on our literature review, we cannot recommend a single best treatment modality for the treatment of Lyme PJI. However, early irrigation and débridement with administration of postoperative antibiotics may improve early clinical outcomes.

Short- and Mid-Term Survival of Geriatric Patients with Septic Arthritis of the Knee and the Impact of Risk Factors on Survival

Septic arthritis is common in older adults and can be related to joint surgery or hematogenous distribution. To date, the risk factors affecting survival are unknown. This study aimed to evaluate the effects of existing implants, positive synovial microbiological culture results, and the American Society of Anesthesiology Physical Status (ASA) classification on the short- and mid-term survival of older patients with primary septic gonarthritis. This retrospective study included 133 older adults >60 years who underwent surgery for primary septic gonarthritis. Data were collected from medical records and public obituaries. Kaplan–Meier survival curves were used to estimate the probability of survival, as well as log-rank tests to measure and compare survival rates over one- and five-year periods. The mean age was 74.9 years (SD ± 9.2), and the 5-year follow-up rate was 74.3% (the mean follow-up was 3000.5 days; SD ± 1771.6). Mean survival was significantly different in patients with implants and without implants (p = 0.015), and between ASA II, ASA III, and ASA IV (p < 0.001). There was no significant difference in the survival of patients with or without a positive synovial microbiological culture (p = 0.08). Older adults with septic monoarthritis and pre-existing medical implants showed impaired survival. The ASA classification prior to surgery for primary septic monoarthritis can be helpful in identifying patients with poorer mid-term outcomes.

Management of prosthetic joint infections: a guidelines comparison

BACKGROUND

In the last decade, the number of prosthetic joint replacements has been rising each year and this growing trend is related to the increased number of prosthetic joint infections (PJI). As PJI represent a devastating condition for the patient, physicians must identify the best treatment option for each case. Guidelines are not always clear regarding the most appropriate therapy pathway as they differ in many parameters.

MATERIALS AND METHODS

Aim of this article is to compare the different indications as reported by four major Academic Societies: the Infectious Disease Society of America, the American Academy of Orthopaedic Surgeons, and the Musculoskeletal Infection Society (MSIS) which published the guideline in partnership with the European Bone And Joint Infection Society.

CONCLUSIONS

PJI Guidelines differ in many parameters, therefore the choice of treatment for each case does not appear immediate; it would be desirable that, in the next few years, new scientific evidence will help clarify the indications of the most effective therapeutic protocols for PJI to determine the ultimate surgical strategy for every single patient.

Synovial calprotectin for the diagnosis of periprosthetic joint infection: a diagnostic meta-analysis

Background

Periprosthetic joint infections (PJI) are a rare but severe complication of total joint arthroplasty (TJA). However, the diagnosis of PJI remains difficult. It is one of the research that focuses about diagnosis for PJI for majority researchers to discover a novel biomarker. This meta-analysis tried to evaluate diagnostic value of synovial calprotectin for PJI.

Methods

This meta-analysis search of the literature was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library. Literature quality was appraised using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) based on RevMan (version 5.3). The diagnostic value of calprotectin for PJI was evaluated by calculating sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), diagnostic score and area under SROC (AUC) based on the Stata version 14.0 software. We conduct subgroup analysis according to the study design, cutoff values, the country of study, and gold standard.

Results

Seven studies were included in this meta-analysis. The pooled sensitivity of synovial calprotectin for the diagnosis of PJI was 0.94 (95% CI, 0.87–0.98), and the specificity was 0.93 (95% CI, 0.87–0.96). The pooled AUC, PLR, and NLR for synovial calprotectin were 0.98 (95% CI, 0.96–0.99), 13.65 (95% CI, 6.89–27.07), and 0.06 (95% CI, 0.02–0.15), respectively. The pooled diagnostic score and DOR were 5.4 (95% CI, 3.96–6.85) and 222.32 (95% CI, 52.52–941.12), respectively.

Conclusion

In summary, this meta-analysis indicates that synovial calprotectin is a promising biomarker of assistant diagnosis for PJI, as well as recommended test for excluding diagnostic tool.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02746-2.

Role of inflammatory markers in the preoperative evaluation of patients undergoing salvage total hip arthroplasty

Surgeons may use laboratory tests, including erythrocyte sedimentation rate, C-reactive protein (CRP), and white blood cell count, as well as joint aspirations to diagnose prosthetic joint infections. There is a paucity of literature correlating preoperative inflammatory markers with risk of infection in the setting of salvage total hip arthroplasty (THA). This retrospective case analysis included patients who underwent a THA salvage procedure a minimum of 3 months after a failed fixation of a proximal femur or acetabulum, with a goal of assessing the utility of inflammatory markers as a screening tool in preoperative evaluation of salvage THA. Eighty-five patients met inclusion criteria. Thirteen patients were diagnosed with an infection preoperatively or intraoperatively during salvage THA. An elevated preoperative CRP level was a significant marker for infection. A CRP of 7.1 produced 80% sensitivity, 88% specificity, and a receiver operating characteristic curve of 0.840. There was a high rate of perioperative complications (17.6%) in salvage THA regardless of the presence of infection. In conclusion, CRP levels are useful in the preoperative evaluation for periprosthetic joint infection before salvage THA.

The alpha defensin lateral flow test is effective in predicting eradication of periprosthetic joint infection after surgical debridement

The primary aim of this study was to assess the utility of the alpha defensin lateral flow (ADLF) test for predicting the eradication of PJI after surgical debridement. The secondary aim was to describe the reliability of ADLF test in diagnosis of PJI intra- operatively. A prospective observational study was conducted in three independent orthopaedic centres. Twenty-two patients undergoing revision surgery (debridement, antibiotics and implant retention (DAIR), single or two-stage revision) for PJI were recruited, 13 female and 9 male with an average age of 64 years. Samples were collected intra-operatively at the start of the first surgical procedure and then at the completion of debridement or prior to reimplantation depending on the operation performed. These samples were tested using ADLF and then sent for microbiological analysis. The ADLF result was then compared to the corresponding culture result in order to determine the diagnostic predictive accuracy. The reliability of ADLF test to predict eradication of infection after debridement of PJI was excellent for specificity and positive predictive value (PPV) of which both where 100%, but had a poor sensitivity (14.3%) and negative predictive value (NPV) (62.5%). The reliability of ADLF test to predict PJI was poor with only a 50% sensitivity and specificity. The ADLF test has a high specificity and PPV for diagnosing eradication of infection after debridement. In contrast the ADLF testing appears to have poor diagnostic accuracy for PJI when used on intra-operative samples, prior to surgical intervention. No benefits or funds were received in suppo

Diagnostic value of fluoroscopy-guided hip aspiration for periprosthetic joint infection

PURPOSE

To assess the value of preoperative joint aspiration in detecting periprosthetic joint infection (PJI) in patients undergoing revision hip arthroplasty and to compare these with the clinical findings, serum markers, and intraoperative findings.

MATERIALS AND METHODS

Fluoroscopically guided hip aspirations in patients with pain after hip arthroplasty were retrospectively reviewed from January 2014 to December 2018. All hips underwent subsequent revision hip arthroplasty. Antibiotics were discontinued at least 2 weeks before the aspiration. The 2018 Musculoskeletal Infection Society (MSIS) criteria served as a standard of reference for PJI. Clinical, serum, synovial, and intraoperative parameters were recorded in all patients. Correlations between all parameters with PJI diagnosis were analyzed using linear and logistic regression models with ROC analysis.

RESULTS

In 202 hips that included 91 septic hips, hip aspiration (AUC = 0.78) and intraoperative (0.80) parameters performed better than serum-based tests (0.64) and clinical parameters (0.68) in detecting PJI. Using MSIS criteria as a standard of reference, hip aspiration had a sensitivity of 64.0% and an accuracy of 78.5% for cultures and a sensitivity of 74.2% and an accuracy of 82.1% for synovial polymorphonuclear neutrophils% (PMN%). Results substantially improved sensitivity after excluding patients that were treated with antibiotics, particularly culture results.

CONCLUSIONS

Preoperative hip aspiration showed good diagnostic performance in diagnosing PJI compared with MSIS criteria as a standard of reference. But a negative result from aspirate could not rule out PJI. Based on our findings, hip aspiration is an essential test for treatment planning in patients with pain after hip arthroplasty.

Use of PET-CT in diagnostic workup of periprosthetic infection of hip and knee joints: significance in detecting additional infectious focus

Introduction

The diagnosis and management of periprosthetic knee and hip infections as well as the identification and management of possible additional infectious foci is of great importance for successful therapy. This study analyses the importance of ¹⁸F deoxyglucose PET-CT (PET-CT) in the identification of additional infectious focus and subsequent impact on management of periprosthetic infection (PPI).

Material and methods

A retrospective analysis of the clinical data and findings in the period from January 2008 to December 2018 was carried out. One hundred and four patients with in-hospital treatment due to PPI of a hip or knee joint were identified and included in this study. All patients underwent a standardized clinical examination and further surgical and antibiotic therapy. The reevaluation of performed PET-CTs was specifically carried out with regard to the local PPI or detection of secondary foci.

Results

PET-CT successfully verified the PPI in 84.2% of the patients. A total of 78 possible additional foci were detected in PET-CT in 56 (53.8%) of the examined patients. Predilection sites for possible secondary foci were joints (42.3%), pulmonary (15.4%), ear-nose-throat (15.4%), spine (11.5%), and the musculocutaneous tissues (11.5%). Fifty-four positive PET-CT findings were confirmed clinically with need of additional adequate treatment.

Conclusion

PET-CT is a valuable diagnostic tool to confirm periprosthetic joint infection. At the same time, the whole-body PET/CT may detect additional foci of infection with impact on subsequent treatment strategy. PET was of special value in detecting infections at distant locations far from the primary infected joint in significant number. These distant infection locations can be potential cause of a re-infection. This clearly reflects the need of their diagnosis.

Periprosthetic Infections of the Shoulder Joint: Characteristics and 5-Year Outcome of a Single-Center Series of 19 Cases

Periprosthetic shoulder infection (PSI) remains a devastating complication after total shoulder arthroplasty (TSA). Furthermore, there is a paucity in the literature regarding its diagnostic and therapeutic management, especially the absence of therapy concepts devised exclusively for PSI. The aim of the presenting study is to examine the characteristics and outcome of patients with PSI who were treated according to well-established algorithms developed originally for periprosthetic joint infection (PJI) of the hip and knee and determine if these algorithms can be applied to PSI. This single-center case series included all patients with a PSI presenting between 2010 and 2020. Recorded parameters included age, sex, affected side, BMI, ASA score, Charlson comorbidity index, preoperative anticoagulation, indication for TSA (fracture, osteoarthritis or cuff-arthropathy), and type of infection (acute or chronic PSI). The outcome was divided into treatment failure or infect resolution. Staphylococcus epidermidis and aureus were the commonest infecting pathogens. Acute PSI was mainly treated with debridement, irrigation, and retention of the prosthesis (DAIR) and chronic cases with two/multiple-stage exchange. The treatment failure rate was 10.5%. C-reactive protein was preoperatively elevated in 68.4% of cases. The mean number of operative revisions was 3.6 ± 2.6, and the mean total duration of antibiotic treatment was 72.4 ± 41.4 days. The most administered antibiotic was a combination of clindamycin and fluoroquinolone. In summary, the data of the current study suggest that therapeutical algorithms and recommendations developed for the treatment of PJI of the hip and knee are also applicable to PSI.