Identification and preoperative optimization of risk factors to prevent periprosthetic joint infection

Surgical site soft tissue thickness as a predictor of complications following arthroplasty

Appreciation of soft-tissue thickness (STT) at surgical sites is an increasingly recognized aspect of arthroplasty procedures as it may potentially impacting postoperative outcomes. Recent research has focused on the predictive value of preoperative STT measurements for complications following various forms of arthroplasty, particularly infections, across procedures such as total knee, hip, shoulder, and ankle replacements. Several studies have indicated that increased STT is associated with a higher risk of complications, including infection and wound healing issues. The assessment of STT before surgery could play a crucial role in identifying patients at a higher risk of complications and may be instrumental in guiding preoperative planning to optimize outcomes in arthroplasty procedures. Standardized measurement techniques and further research are essential to enhance the reliability and clinical utility of STT assessment for arthroplasty surgery.

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

Extended oral antibiotic prophylaxis and PJI-free survivorship after primary total knee arthroplasty

INTRODUCTION

Recent evidence has emerged supporting the use of extended oral antibiotic (EOA) prophylaxis after primary total knee replacement (TKA) to reduce periprosthetic joint infection (PJI) in high-risk patients. However, much of the evidence stems from single-institution series with limited sample sizes. This study aimed to explore the impact of EOA on complications and infection-free survivorship in a large cohort of patients after primary TKA.

METHODS

A large national database was used to identify patients undergoing primary TKA from 2015 to 2022. Patients receiving 7-14 days of EOA were identified. Propensity-score matching, based on patient comorbidities, was used to match patients who received EOA and to control patients who did not. Three cohorts were created: any-risk, high-risk, and standard-risk. Complications at 90-days were assessed with univariate analysis and survivorship free of PJI to 2 years was analyzed with the Kaplan-Meier method and cox regression.

RESULTS

We identified 5,701 patients who received EOA: 3,628 (64%) with high-risk comorbidities and 2,073 (36%) standard risk. There were no significant reduction in hazard of PJI at 90-days (any-risk: HR: 1.65, 95% CI: 0.90-3.04, P = 0.11; high-risk: HR: 1.37, 95% CI: 0.69-2.70, P = 0.4; standard-risk: HR: 1.51, 95% CI: 0.53-4.26, P = 0.4), 1 year (P > 0.07), or 2 years (any-risk: HR: 1.42, 95% CI: 0.98-2.05, P = 0.065; high-risk: HR: 1.14, 95% CI: 0.76-1.73, P = 0.5; standard-risk: HR: 1.51, 95% CI: 0.76-2.98, P = 0.2) with EOA administration.

DISCUSSION

EOA prophylaxis was not associated with improved PJI-free survivorship at any measured time point following primary TKA in either high-risk or standard-risk risk patients. Given the observed widespread use of EOA, our study highlights the need for further investigation to delineate what specific populations may benefit from EOA prophylaxis.

Penile prosthesis for erectile dysfunction: recommendations from the 5th International Consultation on Sexual Medicine

INTRODUCTION

Penile prosthesis (PP) is one of the main approved therapies for erectile dysfunction (ED). Greater than 50 years of clinical use has led to considerable innovation in PP surgery and patient care.

OBJECTIVES

To summarize the current literature and provide updated clinical evidence to inform healthcare providers on best practices with PP.

METHODS

A consensus panel was held with leading sexual medicine experts during the 5th International Consultation on Sexual Medicine (ICSM). Relevant peer-reviewed literature was reviewed with focus on research from but not limited to the last 10 years. The quality of each individual study was judged with Oxford levels of evidence (LOE) criteria, but overall LOE were not used as systematic review was not performed. The expert panel generated consensus statements based on the quality of evidence and criteria of GRADE (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

PP provides excellent outcomes for the treatment of ED. The panel developed 35 recommendations building upon previous recommendations. Nine recommendations (4, 5, 11,13,17, 25, 26, 31, and 32) are retained without change from 2015. Twelve recommendations (1, 2, 3, 7, 9,14,16,19,21, 28, 33, and 34) change syntax to make statements more active or change details. Fourteen recommendations (6, 8, 10, 12, 15, 18, 20, 22, 23, 24, 27, 29, 30, and 35) are novel in this update.

CONCLUSION

Since the 4th ICSM, new evidence has emerged to guide PP use in modern sexual medicine. While multi-institutional studies are needed to improve outcomes, key challenges remain: reducing infections, enhancing devices, and improving awareness and accessibility. We recommend following 5th ICSM guidelines while emphasizing the importance of clinical judgment and shared decision-making for optimal PP outcomes.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

Microbiological profiles in periprosthetic joint infections after total knee arthroplasty: a comparative analysis of diabetic and non-diabetic patients

AIM OF THE STUDY

The purpose of this study is to conduct a comparative analysis of the microbiological profiles in periprosthetic joint infections (PJIs) after total knee arthroplasty (TKA) between diabetic and non-diabetic patients. The study aims to address what are the variations in microbial colonization and infection patterns between diabetic and non-diabetic patients undergoing total knee arthroplasty.

METHODS

A retrospective analysis of 2,569 culture-positive cases of PJIs post-TKA was conducted, comparing outcomes between diabetic (n = 321) and non-diabetic (n = 2,248) patients. Demographic, clinical, and microbiological data were collected and analyzed using descriptive statistics, chi-squared tests, logistic regression, and other statistical tests.

RESULTS

Diabetic patients exhibited distinct microbial colonization patterns, with a higher prevalence of pathogens such as Staphylococcus aureus (p = 0.033), Pseudomonas aeruginosa (p < 0.001), Streptococcus spp. (Streptococcus agalactiae and Streptococcus dysgalactiae; p = 0.010, 0.016 respectively), Candida spp. (p = 0.010), and Corynebacterium spp. (p = 0.024). Additionally, diabetic patients were at increased risk of polymicrobial infections. Comorbidities associated with diabetes, including chronic pulmonary disease, renal insufficiency, and peripheral artery disease, were significantly more prevalent in diabetic patients and further complicated PJI outcomes.

CONCLUSION

This study underscores the importance of tailored perioperative antimicrobial strategies and vigilant infection control measures in diabetic patients undergoing TKA. Understanding the differential microbial profiles and associated comorbidities can inform targeted interventions to mitigate the risk of PJIs and improve outcomes in this high-risk population. Further research is warranted to elucidate the underlying mechanisms and optimize management strategies for diabetic patients undergoing TKA.

The Effect of Nutritional Status in the Treatment of Periprosthetic Joint Infections in Total Hip Arthroplasty

BACKGROUND

Periprosthetic joint infections (PJIs) continue to be a complication that plagues arthroplasty. Albumin is a surrogate marker for nutrition as well as chronic inflammation, and hypoalbuminemia increases the risk of complications in arthroplasty. Patients with PJI are at increased risk for malnutrition and complications. This study's objective was to analyze patients who underwent treatment of PJI following total hip arthroplasty and investigate the outcome with regards to albumin levels.

METHODS

Overall, 48 patients who underwent surgery for a total hip PJI at 1 institution were reviewed. Albumin and C-reactive protein were recorded preoperatively and 2 to 3 weeks postoperatively. Treatment failure was determined by further surgical treatment for PJI or repeat infection, as determined by Musculoskeletal Infection Society guidelines.

RESULTS

A debridement, antibiotics, and implant retention procedure was performed in 39 patients, and explant with the placement of an antibiotic spacer was performed in 9. Preoperative mean albumin levels were significantly decreased in patients who failed to clear their infection compared to patients who remained infection-free (2.5 versus 3.3, P < .001). Postoperative albumin levels decreased in this same population (2.6 versus 3.8, P < .001). C-reactive protein was elevated in patients who failed to clear their infection preoperatively (19.9 versus 7.5, P < .001) and postoperatively (7.0 versus 1.7, P < .001). The average time to repeat surgical treatment for their PJI was 9 months CONCLUSIONS: Lower albumin levels are observed in patients with PJI who failed to remain infection-free after surgery. Albumin is a surrogate marker for nutrition, and low albumin is associated with poor immune function. Hypoalbuminemia is found with chronic inflammation as well as malnutrition. Nutritional reserves are diverted to the acute inflammatory response during an infection, which can lead to a deficient state. Further research may develop treatments to alter this modifiable risk factor.

LEVEL OF EVIDENCE

Level 4.

Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis

BACKGROUND

This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery.

METHODS

A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables.

RESULTS

Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty.

CONCLUSIONS

There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex.

LEVEL OF EVIDENCE

III.

Periprosthetic Joint Infections of the Knee-Comparison of Different Treatment Algorithms

Background: Periprosthetic joint infection (PJI) following total knee arthroplasty is a serious complication lacking evidence-based diagnostic and treatment protocols, particularly in ruling out persisting infection before reimplantation. Methods: This retrospective analysis assessed the mid-term outcomes of 66 patients undergoing septic two-stage knee revision surgeries from 2007 to 2013, diagnosed as per the Musculoskeletal Infection Society criteria. After implant removal and antibiotic treatment, reimplantation decisions were based on either joint aspiration, blood counts, and clinical examination (group A) or an open biopsy (group B). Both groups underwent meticulous debridement and spacer exchange during the interim period. Results: Late re-infection occurred in 12.1% of all patients. In group A, 13.8% experienced late re-infection, with 14.3% in subgroup A1 and 13.3% in subgroup A2. In group B, 10% had a late re-infection. No significant difference in re-infection or complication rates was found between the groups. Conclusions: The study did not demonstrate the superiority of group B's approach of open biopsy over group A's joint aspiration, clinical examination, and blood counts in preventing re-infection or reducing complications.

What Is the Most Effective Treatment for Periprosthetic Joint Infection After Total Joint Arthroplasty in Patients with Rheumatoid Arthritis?: A Systematic Review

BACKGROUND

Rheumatoid arthritis (RA) is a risk factor for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of this study was to perform a systematic review comparing the failure rates of debridement, antibiotics, and implant retention (DAIR), one-stage exchange arthroplasty/revision (OSR), and 2-stage exchange arthroplasty/revision (TSR) for RA patients with PJI and identify risk factors in the RA population associated with increased treatment failure rate.

METHODS

PubMed, Ovid MEDLINE, and Ovid Embase databases were screened with the terms "rheumatoid arthritis," "total joint arthroplasty," "prosthetic joint infection," and "treatment for PJI" on August 29, 2021. Four hundred ninety-one studies were screened, of which 86 were evaluated. The primary outcome evaluated was failure of surgical treatment for PJI.

RESULTS

Ten retrospective cohort studies were included after full-text screening, yielding 401 patients with RA. Additional demographic and PJI management data were obtained for 149 patients. Patients with RA who underwent TSR demonstrated a lower failure rate (26.8%) than both DAIR (60.1%) and OSR (39.2%) (χ2 = 37.463, p < 0.00001). Patients with RA who underwent DAIR had a 2.27 (95% CI, 1.66-3.10) times higher risk of experiencing treatment failure than those who underwent TSR. Among risk factors, there was a significant difference in the C-reactive protein of patients who did vs. did not experience treatment failure (p = 0.02).

CONCLUSION

TSR has a higher rate of success in the management of PJI patients with RA compared with DAIR and OSR. The complete removal of the infected prosthesis and delayed reimplantation may lower the treatment failure rate.

LEVEL OF EVIDENCE

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

Comparison of Surgical Procedures in the Treatment of Hip Periprosthetic Infection

Objective The present study aimed to compare the cure rate recovery time and Merle d'Aubigné-Postel functional (MAPF) score after single-stage surgery (C1T) or two-stage surgery (C2T) to treat prosthetic infections of the hip considering sociodemographic and clinical features of the patients. Materials and Methods The present retrospective study occurred in a single center from 2011 to 2014 with 37 studied cases including 26 treated with C1T and 11 with C2T. We compared the cure rate recovery time and MAPF score in the two groups as well as the sociodemographic and clinical features of the patients. We also considered surgical complications and the most common infectious agents. Results The C1T group had a faster functional recovery than the C2T group but there were no significant differences in the cure rate surgical complications or MAPF score. However C1T group patients were significantly younger which may have influenced the outcomes. Staphylococcus spp. was the most common infectious agent (62%). Conclusion Although C2T appears superior regarding infection cure C1T may be preferable for faster functional recovery. However it is critical to consider individual patient characteristics when choosing treatment. Further research with a larger sample size is required to confirm these results.

Visceral Fat as a Risk Factor for Periprosthetic Joint Infection After Total Hip and Knee Arthroplasty

BACKGROUND

Visceral obesity, a strong indicator of chronic inflammation and impaired metabolic health, has been shown to be associated with poor postoperative outcomes and complications. This study aimed to evaluate the relationship between visceral fat area (VFA) and periprosthetic joint infection (PJI) in total joint arthroplasty (TJA) patients.

METHODS

A retrospective study of 484 patients who had undergone a total hip or knee arthroplasty was performed. All patients had a computed tomography scan of the abdomen/pelvis within two years of their TJA. Body composition data (ie, VFA, subcutaneous fat area, and skeletal muscle area) were calculated at the Lumbar-3 vertebral level via two fully automated and externally validated machine learning algorithms. A multivariable logistic model was created to determine the relationship between VFA and PJI, while accounting for other PJI risk factors. Of the 484 patients, 31 (6.4%) had a PJI complication.

RESULTS

The rate of PJI among patients with VFA in the top quartile (> 264.1 cm2) versus bottom quartile (< 82.6 cm2) was 5.6% versus 10.6% and 18.8% versus 2.7% in the total hip arthroplasty and total knee arthroplasty cohorts, respectively. In the multivariate model, total knee arthroplasty patients with a VFA in the top quartile had a 30.5 times greater risk of PJI than those in the bottom quartile of VFA (P = .0154).

CONCLUSION

VFA may have a strong association with PJI in TJA patients. Using a standardized imaging modality like computed tomography scans to calculate VFA can be a valuable tool for surgeons when assessing risk of PJI.

Comparison of mortality rate and septic and aseptic revisions in total hip arthroplasties for osteoarthritis and femoral neck fracture: an analysis of the German Arthroplasty Registry

BACKGROUND

Indications for total hip arthroplasties (THA) differ from primary osteoarthritis (OA), which allows elective surgery through femoral neck fractures (FNF), which require timely surgical care. The aim of this investigation was to compare mortality and revisions in THA for primary OA and FNF.

METHODS

Data collection for this study was performed using the German Arthroplasty Registry (EPRD) with analysis THA for the treatment of FNF and OA. Cases were matched 1:1 according to age, sex, body mass index (BMI), cementation, and the Elixhauser score using Mahalanobis distance matching.

RESULTS

Overall 43,436 cases of THA for the treatment of OA and FNF were analyzed in this study. Mortality was significantly increased in FNF, with 12.6% after 1 year and 36.5% after 5 years compared with 3.0% and 18.7% in OA, respectively (p < 0.0001). The proportion for septic and aseptic revisions was significantly increased in FNF (p < 0.0001). Main causes for an aseptic failure were mechanical complications (OA: 1.1%; FNF: 2.4%; p < 0.0001) and periprosthetic fractures (OA: 0.2%; FNF: 0.4%; p = 0.021). As influencing factors for male patients with septic failure (p < 0.002), increased BMI and Elixhauser comorbidity score and diagnosis of fracture (all p < 0.0001) were identified. For aseptic revision surgeries, BMI, Elixhauser score, and FNF were influencing factors (p < 0.0001), while all cemented and hybrid cemented THA were associated with a risk reduction for aseptic failure within 90 days after surgery (p < 0.0001).

CONCLUSION

In femoral neck fractures treated with THA, a significant higher mortality, as well as septic and aseptic failure rate, was demonstrated compared with prosthesis for the therapy of osteoarthritis. Increased Elixhauser comorbidity score and BMI are the main influencing factors for development of septic or aseptic failure and can represent a potential approach for prevention measures.

LEVEL OF EVIDENCE

Level III, Prognostic.

Intraosseous Regional Administration of Antibiotic Prophylaxis for Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Intraosseous regional administration (IORA) of antibiotics after tourniquet inflation has recently been introduced as a technique to deliver antibiotics directly to the surgical site among patients undergoing total knee arthroplasty (TKA).

METHODS

PubMed and Embase were queried for studies reporting on IORA for perioperative prophylaxis during TKA. Primary outcome measures were local tissue antibiotic concentrations and rates of prosthetic joint infection (PJI). Eight studies were included for analysis. Four studies (all randomized controlled trials) compared local tissue concentrations between patients receiving IORA and intravenous (IV) antibiotics. Six studies assessed the rate of PJI among patients receiving IORA versus IV antibiotics.

RESULTS

All studies found a statistically significant increase in antibiotic concentration in femoral bone and fat samples in patients who were treated with IORA (44.04 μg/g [fat] and 49.3 μg/g [bone] following 500 mg of intraosseous vancomycin) versus IV (3.5 μg/g [fat] and 5.2 μg/g [bone] following 1 g IV of vancomycin). The two studies powered to determine differences in PJI rates found a statistically significant decrease in the rate of PJI among patients receiving IORA versus IV antibiotics. The incidence of PJI in patients treated with IORA and IV antibiotics across all studies was 0.3 and 1.1%, respectively.

CONCLUSION

Perioperative IORA of antibiotics in TKA provides local tissue concentrations of antibiotics that are on average 10 times higher than IV administration alone. Although more adequately powered investigations are necessary to determine the effectiveness of IORA in reducing PJI rates, adoption of IORA should be considered in high-risk patients where elevated tissue antibiotic concentrations would be of a maximum benefit.

Relationship Between Preoperative Nutritional Status and Predicting Short-Term Complications Following Revision Total Hip Arthroplasty

BACKGROUND

The association between malnutrition and complications following primary total joint arthroplasty is well-delineated, however, nutritional status has yet to be explored specifically in revision total hip arthroplasty (THA). Therefore, our objective was to examine if a patient's nutritional status based on body mass index, diabetic status, and serum albumin predicted complications following a revision THA.

METHODS

A retrospective national database review identified 12,249 patients who underwent revision THA from 2006 to 2019. Patients were stratified based on body mass index (<18.5=underweight, 18.5 to 29.9=healthy/overweight, >30=obese), diagnosis of diabetes (no diabetes, insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM)), and preoperative serum albumin (<3.5=malnourished, >3.5=non-malnourished). Multivariate analyses was performed using Chi-squared tests and multiple logistic regressions.

RESULTS

In all groups including underweight (1.8%), healthy/overweight (53.7%), and obese (44.5%), those without diabetes were less likely to be malnourished (p<0.001), while those with IDDM had a higher rate of malnutrition (p<0.001). Underweight patients were significantly more malnourished compared to healthy/overweight or obese patients (p<0.05). Malnourished patients had an increased risk of wound dehiscence/surgical site infections (p<0.001), urinary tract infection (p<0.001), requiring a blood transfusion (p<0.001), sepsis (p<0.001), and septic shock (p<0.001). Malnourished patients also have worse postoperative pulmonary and renal function.

CONCLUSIONS

Patients who are underweight or have IDDM are more likely to be malnourished. The risk of complications within 30 days of surgery following revision THA significantly increases with malnutrition. This study shows the utility of screening underweight and IDDM patients for malnutrition prior to revision THA to minimize complications.

C9 immunostaining as a tissue biomarker for periprosthetic joint infection diagnosis

Background

Culture-negative periprosthetic joint infections (PJI) are often false diagnosed as aseptic implant failure leading to unnecessary revision surgeries due to repeated infections. A marker to increase the security of e PJI diagnosis is therefore of great importance. The aim of this study was to test C9 immunostaining of periprosthetic tissue as a novel tissue-biomarker for a more reliable identification of PJI, as well as potential cross-reactivity.

Method

We included 98 patients in this study undergoing septic or aseptic revision surgeries. Standard microbiological diagnosis was performed in all cases for classification of patients. Serum parameters including C-reactive protein (CRP) serum levels and white blood cell (WBC) count were included, and the periprosthetic tissue was immunostained for C9 presence. The amount of C9 tissue staining was evaluated in septic versus aseptic tissue and the amount of C9 staining was correlated with the different pathogens causing the infection. To exclude cross-reactions between C9 immunostaining and other inflammatory joint conditions, we included tissue samples of a separate cohort with rheumatoid arthritis, wear particles and chondrocalcinosis.

Results

The microbiological diagnosis detected PJI in 58 patients; the remaining 40 patients were classified as aseptic. Serum CRP values were significantly increased in the PJI cohort. Serum WBC was not different between septic and aseptic cases. We found a significant increase in C9 immunostaining in the PJI periprosthetic tissue. To test the predictive value of C9 as biomarker for PJI we performed a ROC analyses. According to the Youden's criteria C9 is a very good biomarker for PJI detection with a sensitivity of 89% and a specificity of 75% and an AUC of 0.84. We did not observe a correlation of C9 staining with the pathogen causing the PJI. However, we observed a cross reactivity with the inflammatory joint disease like rheumatoid arthritis and different metal wear types. In addition, we did not observe a cross reactivity with chondrocalcinosis.

Conclusion

Our study identifies C9 as a potential tissue-biomarker for the identification of PJI using immunohistological staining of tissue biopsies. The use of C9 staining could help to reduce the number of false negative diagnoses of PJI.

Two-stage revision hip arthroplasty in the treatment of periprosthetic joint infection

Introduction. One of the rare complications following hip arthroplasty is periprosthetic joint infection (PJI). Two-stage revision arthroplasty is the gold standard in the treatment of deep periprosthetic infection of large joints, providing high probability of infection process resolution as well as functional recovery of the limb and elimination of pain syndrome.

Aim: to improve the treatment results of patients with periprosthetic infection after primary hip arthroplasty.

Materials and Methods. 121 patients (62 patients in the main group and 59 in the control group) after primary hip arthroplasty were included in the study. In the main group, treatment was performed using a two-stage technique with implantation of a preformed spacer and our proposed algorithm. In the control group, treatment was performed using a homemade spacer and without using the developed algorithm.

Results. When using our developed treatment algorithm, a good result in the treatment of UTI was achieved. The infectious process was controlled in 80.6 % of cases, as compared with 64.4 % in the control group, which is comparable with the data of domestic and foreign literature.

Conclusion. Treatment of patients with periprosthetic infection should be performed only in specialized centers that perform all stages of treatment, have all necessary instruments, an equipped operating room, necessary drugs in the hospital pharmacy, experienced staff and equipped bacteriological laboratory, as well as many years of experience of surgeons with these patients.

Could Short Stems THA Be a Good Bone-Saving Option Even in Obese Patients?

Short femoral stems, with preservation of the femoral bone stock, are commonly used in recent years for hip replacement in younger and more active patients. Obesity is increasingly spreading even in the younger population. The aim of this case-series study is to evaluate short stems compared to traditional hip prostheses in the obese population. A total of 77 consecutive patients with a BMI greater than or equal to 30 Kg/m2 were enrolled in this prospective study and were divided into two groups: 49 patients have been implanted with short stems while 28 patients were implanted with traditional stems. All the patients were treated for primary osteoarthritis or avascular necrosis and all the stems were implanted by the same surgeon using a posterior approach. Clinical (Harris Hip Score—HHS, Western Ontario and McMaster Universities Osteoarthritis Index—WOMAC, visual analogue scale—VAS, 12-item Short Form Health Survey—SF-12) and radiographic outcomes were recorded. Radiological evaluations were carried out by three different blinded surgeons. A statistical analysis was performed (chi-square, t-test, Wilcoxon Rank Sum Test, 2-factor ANOVA). At a mean follow-up of 42.6 months both groups showed a marked improvement in pain and in the clinical scores between pre- and post-surgical procedures (p < 0.05) with no significant differences between the two groups at last follow-up (p > 0.05). The radiological evaluations, with high concordance correlation between the three blinded surgeons (ICC consistently >0.80), showed good positioning and osseointegration in all cases, with no significant differences in the restoration of the joint geometry and complications. No revisions were recorded during the follow-up period. In conclusion, short stems appear to be a good option for bone preservation even in obese patients, showing comparable results to traditional implants.

Impact of socioeconomic status on the 90- and 365-day rate of revision and mortality after primary total hip arthroplasty: a cohort study based on 103,901 patients with osteoarthritis from national databases in Denmark

Background and purpose - Socioeconomic inequality in health is recognized as an important public health issue. We examined whether socioeconomic status (SES) is associated with revision and mortality rates after total hip arthroplasty (THA) within 90 and 365 days.Patients and methods - We obtained SES markers (cohabitation, education, income, and liquid assets) on 103,901 THA patients from Danish health registers (year 1995-2017). The outcomes were any revision (all revisions), specified revision (due to infection, fracture, or dislocation), and mortality. We used Cox regression analysis to estimate adjusted hazard ratio (aHR) of each outcome with 95% confidence interval (CI) for each SES marker.Results - Within 90 days, the aHR for any revision was 1.3 (95% CI 1.1-1.4) for patients living alone vs. cohabiting. The aHR was 2.0 (CI 1.4-2.6) for low-income vs. high-income among patients < 65 years. The aHR was 1.2 (CI 0.9-1.7) for low liquid assets among patients > 65 years. Results were consistent for any revision within 365 days as well as for revisions due to infection, fracture, and dislocation. The aHR for mortality was 1.4 (CI 1.2-1.6) within 90 days and 1.3 (CI 1.2-1.5) within 365 days for patients living alone vs. cohabiting. Low education, low income, and low liquid assets were associated with increased mortality rate within both 90 and 365 days.Interpretation - Our results suggest that living alone, low income, and low liquid assets were associated with increased revision and mortality up to 365 days after THA surgery. Optimizing medical conditions prior to surgery and implementing different post-THA support strategies with a focus on vulnerable patients may reduce complications associated with inequality.

Proton-pump inhibitors are associated with increased risk of prosthetic joint infection in patients with total hip arthroplasty: a case-cohort study

Background and purpose - Proton-pump inhibitors (PPI) have previously been associated with an increased risk of infections such as community-acquired pneumonia, gastrointestinal infections and central nervous system infection. Therefore, we evaluated a possible association between proton-pump inhibitor use and prosthetic joint infection (PJI) in patients with total hip arthroplasty (THA), because they can be stopped perioperatively or switched to a less harmful alternative.Patients and methods - A cohort of 5,512 primary THAs provided the base for a case-cohort design; cases were identified as patients with early-onset PJI. A weighted Cox proportional hazard regression model was used for the study design and to adjust for potential confounders.Results - There were 75 patients diagnosed with PJI of whom 32 (43%) used PPIs perioperatively compared with 75 PPI users (25%) in the control group of 302 patients. The risk of PJI was 2.4 times higher (95% CI 1.4-4.0) for patients using PPI. This effect remained after correction for possible confounders.Interpretation - The use of PPIs was associated with an increased risk of developing PJI after THA. Hence, the use of a PPI appears to be a modifiable risk factor for PJI.

Medico-Legal Issues Related to Hip and Knee Arthroplasty: A Literature Review Including the Indian Scenario

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed surgeries worldwide. The number of joint replacement surgeries being performed has increased considerably over the past two decades, but it has also seen an increase in litigation associated with it. The purpose of our study was to review and consolidate literature regarding medico-legal issues pertaining to THA and TKA cases. We looked at the causes of litigation, medico legal aspects of pre-operative requirements, optimisation of medical condition, indications and contraindications for arthroplasty, informed consent, implants, mixing of components from different manufacturers and post-operative rehabilitation. We also wanted to analyse available literature and legal proceedings regarding these cases in India specifically.

Usefulness of Perioperative Laboratory Tests in Total Hip and Knee Arthroplasty: Are They Necessary for All Patients?

BACKGROUND

Laboratory studies are routinely obtained preoperatively and postoperatively for total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study evaluates the necessity of routine, perioperative laboratory tests and identifies risk factors for laboratory-associated interventions.

METHODS

This retrospective review evaluated 967 consecutive patients scheduled for primary, unilateral TKAs (n = 593) or THAs (n = 374) over an 18-month period at a single institution. Preoperative prothrombin time (PT) and International Normalized Ratio (INR), complete blood count (CBC), complete metabolic panel (CMP), and postoperative CBC and basic metabolic panel (BMP) were recorded along with any laboratory-associated intervention. Patient demographics and comorbidities identified risk factors for abnormal or actionable laboratory studies.

RESULTS

Preoperatively, the actionable rates for PT/INR, CMP, and CBC were 0.3%, 1.4%, and 0.5%, respectively. Vascular, renal, and immunologic diseases were risk factors for an actionable CBC. Risk factors for an actionable CMP include cardiac arrhythmia and diabetes. There were no risk factors for an actionable PT/INR. Postoperatively, only 1.5% of BMPs and 1.5% of CBCs were actionable. Congestive heart failure, renal disease vascular disease, or history of cancer (P = .030) were risk factors for an actionable CBC. There were no risk factors for an actionable BMP. Patients with an abnormal preoperative lab were 2.4 times more likely to have an actionable postoperative lab. Patients with an actionable preoperative lab were 11.3 times more likely to have an actionable postoperative lab.

CONCLUSION

Routine preoperative and postoperative labs may not be necessary on all patients undergoing a TKA or THA. Comorbid risk factors and abnormal or actionable preoperative CMPs and CBCs can help determine the usefulness of postoperative laboratory assessments.

Experience with periprosthetic infection after limb salvage surgery for patients with osteosarcoma

Background

The rate of postoperative infection developing is higher after limb salvage surgery (LSS) following sarcoma resection compared with conventional arthroplasty. The goal of this study is to summarize our experience in management of periprosthetic joint infection (PJI) and the risk factors of early PJI after LSS.

Methods

Between January 2010 and July 2019, 53 patients with osteosarcoma in the lower extremities who encountered periprosthetic infection after segmental tumor endoprosthetic replacement in our center were analyzed. Detailed patient characteristics and therapeutic information were collected from database of our institution or follow-up data and we divided patients according to the interval time between infection and tumor resection (surgery-infection interval) and investigate potential risk factors.

Results

A total of 53 (5.08%) patients were suffered postoperative infection. The average interval between surgery and clinical signs of deep infections are 27.5 days. For the drainage culture, positive results were only presented in 11 patients (20.8%). Almost half of this study’s (47.2%) patients underwent a traditional two-stage revision, that was, after the removal of the infected prosthesis, we applied antibiotic-loaded bone cements as a spacer. The mean blood loss during initial implantation surgery and operation time both correlated with interval period between PJI and initial implantation significantly (P = 0.028, P = 0.046). For several patients which infection marker was hardly back to normal after spacer implantation, we conservatively introduced an improved combination of bone cement and prosthesis for the second-stage surgery (5.6%). There were six patients needing re-operation, of which three were due to the aseptic loosening of the prosthesis, one developed periprosthetic infection again, and two patients encountered local recurrence and underwent amputation. Two patients were dead from distal metastasis.

Conclusions

A two-stage revision strategy remains effective and standardized methods for PJI patients. Total operation time and blood loss during LSS of osteosarcoma are the main risk factors of early PJI. For the patients without confirmed eradiation of microorganisms, an improved combination of bone cement and prosthesis applied in the second-stage surgery could achieve satisfied functional and oncologic results.

Progress in Prevention, Diagnosis, and Treatment of Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) after joint replacement surgery is a severe complication associated with high morbidity and increased treatment costs. More than 25% of joint implant failures are attributed to PJI. PJI diagnosis and treatment methods have substantially improved in recent years. However, the prevalence of PJI remains high, primarily due to the increased prevalences of obesity, diabetes, and other underlying conditions. Moreover, increasing elderly prefers to total joint replacement surgery. However, due to frailty and comorbidities, most are at increased risk of infectious arthritis and artificial joint infection (PJI). Therefore, PJI management for the elderly requires multilevel and multiangle intervention. In this review, we summarize the risk factors and diagnostic methods currently available for PJI and discuss the current PJI prevention and treatment interventions, especially the management in older adults.

Elevated HbA1c is not a risk factor for wound complications following total joint arthroplasty: a prospective study

BACKGROUND

Controversies exist regarding the association of elevated serum glycated haemoglobin (HbA1c) levels and postoperative surgical site infection (SSI) or prosthetic joint infection (PJI) in the setting of total hip and knee arthroplasty (THA and TKA). The purpose of the current study was to determine the prevalence of unknown and uncontrolled diabetes mellitus (DM) in a consecutive series and to investigate the association between postoperative wound complications or SSI/PJI and elevated HbA1c in patients undergoing TJA.

METHODS

In this prospective single-centre study, HbA1c was determined for patients undergoing elective primary, aseptic or septic revision THA and TKA, between September 2017 and March 2018. Prevalence of DM, unknown and uncontrolled diabetes were reported. Occurrence of 90-day wound healing disorders (WHD) as well as SSI or PJI were observed. Considering the HbA1c threshold ⩾6.5%, a comparative analysis between patients with and without WHD and SSI or PJI for the whole study cohort, as well as for each arthroplasty group, was performed. Receiver operating characteristic (ROC) curves were developed to quantify the predictive power of HbA1c with regard to WHD and infection complications. A total of 1488 patients were included for final analysis. There were 1127 primary THA and TKA (75.7%), 272 aseptic revisions (18.3%) and 89 septic revisions (6.0%). The known diabetic patients constituted 9.9% of the whole study cohort.

RESULTS

The majority had uncontrolled DM (67%). Prevalence of unknown DM was 11.1%. The results reveal the prevalence for the German population and might be different in other regions. A total of 57 patients (3.7%) experienced postoperative wound or infectious complications. PJI occurred in only 5 patients (0.03%). There was no significant difference between patients with HbA1c <6.5% and patients with HbA1c ⩾6.5% (p = 0.092).

CONCLUSIONS

We demonstrated that prevalence of unknown and uncontrolled DM in patients undergoing TJA is increasing, however; routine preoperative determination of the HbA1c value to prevent possible postoperative wound or infectious complications remains debatable. Larger studies investigating the optimal HbA1c level, as well as other predictors are required.

Are Patients With a History of Septic Arthritis Undergoing Total Knee Arthroplasty at Higher Risk for Revision Surgery? A Single-Center Study

BACKGROUND

The decision to perform a total knee arthroplasty (TKA) on a previously infected knee is made complicated by the higher risk for both a periprosthetic joint infection (PJI) and early failure. There is currently no standard in the treatment strategy for this group of patients. We here report the outcomes of performing a primary TKA on patients with a prior septic knee arthritis. The aim of our study is to analyze the survival rates of patients with a history of septic arthritis undergoing TKA.

METHODS

From 2010 to 2018, all patients treated in our institution with a minimum follow-up of 1 year, who have previous histories of knee joint infections and underwent a primary TKA were included in the study. All patients underwent the same surgical protocol and were given systemic and local antibiotic treatment.

RESULTS

Of the 68 knees, there were 4 surgical revisions (5.9%). These included 2 septic revisions due to PJI (2.9%), 1 open arthrolysis for arthrofibrosis (1.5%), and 1 aseptic revision for implant loosening (1.5%). Sixty-four (64) knees (94%) had survived without any surgical interventions and the Kaplan-Meier analysis demonstrated an overall survivorship free from PJI of 97.1% at a mean of 5 years (range 1-9, standard deviation ±2.5 years).

CONCLUSION

TKA is a suitable option for patients with a prior septic arthritis of the knee, provided that proper surgical technique and the utilization of systemic and local antibiotics are employed.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Periprosthetic knee infection reconstruction with a hinged prosthesis: Implant survival and risk factors for treatment failure

BACKGROUND

Severe bone and soft tissue defects are common after failed two-stage exchange arthroplasty for periprosthetic joint infection (PJI). There is a paucity of evidence on the outcomes of using a hinged prosthesis for knee PJI reconstruction during second-stage re-implantation, especially regarding implant survivorship, reinfection risk factors, and functionality after successful reconstruction.

METHODS

A total of 58 knee PJI patients with Anderson Orthopaedic Research Institute (AORI) type II/III defect and soft tissue insufficiency underwent reconstruction with hinged prosthesis. Enrolled patients adhered to a two-stage exchange arthroplasty protocol and were evaluated for a mean follow up of 65.1 months. Kaplan-Meier analysis was conducted for implant survivorship and infection-free survival. Multivariate analysis was used to determine independent risk factors for recurrent infections. Knee Society Score (KSS) was used to evaluate functional outcomes.

RESULTS

The survivorship of hinged prosthesis was 86.2% at 2 years and 70.2% at 5 years. Infection-free analysis revealed an estimation of 68.9% at 2 years and 60.6% at 5 years. Of the 58 patients, 13 (22.4%) developed recurrent PJI, three (5.2%) aseptic loosening, and one (1.7%) periprosthetic fracture. Multivariate analysis revealed that obesity (hazard ratio (HR), 3.11), high-virulent pathogen (HR, 3.44), and polymicrobial infection (HR, 3.59) were independent risk factors for reinfection. Patients showed a mean improvement of 32.8 ± 7.7 in Knee Society Clinical Score (KSCS) and 30.8 ± 11.0 in Knee Society Function Score (KSFS) after successful reconstruction (P<0.001).

CONCLUSIONS

Using hinged knee prosthesis for PJI reconstruction provided an overall implant survival of 70.2% and an infection-free survival of 60.6% at mid-term follow up. Obesity, virulent pathogens, and polymicrobial infections were independent risk factors for infection recurrence.

The Cumulative Effect of Substance Abuse Disorders and Depression on Postoperative Complications After Primary Total Knee Arthroplasty

BACKGROUND

Substance abuse disorder (SUD), alcohol abuse disorder (AUD), and depression have been identified as independent risk factors for complications after total knee arthroplasty (TKA). However, these mental health disorders are highly co-associated, and their cumulative effect on postoperative complications have not been investigated. Therefore, this study aimed to determine if patients who have more than one mental health disorder (SUD, AUD, or depression) were at an increased risk for postoperative complications following TKA.

METHODS

A total of 11,403 TKA patients were identified from a prospectively collected institutional database between January 1, 2017 and April 1, 2019. Patients who had depression, SUD, and AUD were separated into 7 mental health subgroups including each of these diagnoses alone and their combined permeations. Patient demographics, body mass indices, medical comorbidities, and 15 postoperative complications were collected. Univariate analyses were performed using independent Student's t-tests. Multivariate analyses were then performed to identify odds ratios (ORs) for mental health disorders subgroups associated with complications.

RESULTS

We found a total of 2073 (18%) patients diagnosed with either SUD (4%), AUD (0.6%), or depression (12%). Univariate analyses showed that depression was associated with mechanical failures (P < .001). SUD was associated with periprosthetic joint infection (PJI) (P < .001), wound complications (P = .022), and aseptic loosening (P = .007). AUD was associated with PJI (P < .001) and deep vein thromboses (P = .003). Multivariate analyses found that AUD (OR: 19.419, P < .001) and SUD (OR:3.693, P = .010) were independent risk factors for PJI. Compared with SUD alone, patients with depression plus SUD were found to have a 4-fold (OR: 13.639, P < .001) and 2-fold (OR:4.401, P = .021) increased risk for PJI and cellulitis, respectively.

CONCLUSIONS

Patients who had depression, SUD, or AUD were at increased risk for postoperative complications following primary TKA. When patients have more than one mental health diagnosis, their risk for complications was amplified. The results of this study can help identify those patients who are at greater risk of postoperative complications to enable improved preoperative optimization and patient education.

Identifying Risk Factors Associated With Postoperative Infection Following Elective Lower-Extremity Total Joint Arthroplasty

This article addresses the importance of identifying risk factors associated with postoperative infection following elective lower-extremity total joint arthroplasty. Specifically, this review discusses risk factors recognized by the American Academy of Orthopaedic Surgeons that should be carefully considered and assessed by the orthopaedic team in collaboration with the primary care provider before proceeding with surgery.

Negative Pressure Incisional Therapy and Infection After Direct Anterior Approach Primary Total Hip Arthroplasty

With the aging of the US population, total hip arthroplasty (THA) is becoming an increasingly common procedure. A major concern after THA is reducing infection rates, as infections can cause devastating complications. Improved sterile technique, standardized infection control protocols, and novel dressings have been used to reduce postoperative surgical site infections (SSIs). The use of either silver-impregnated dry dressings or easily applied incisional negative pressure dressings is aimed at reducing the rates of SSIs after primary anterior THA. The authors retrospectively reviewed the medical records of 275 patients who underwent anterior THA at their institution during a 1-year period. Patients were separated into groups based on their surgical dressing. Rates of SSI were documented, and the effects of various factors, including age, sex, body mass index, and comorbidities, were compared between the 2 cohorts. The authors also analyzed high-risk patients to determine whether easily applied incisional negative pressure dressings reduced infections. The use of easily applied incisional negative pressure dressings after primary anterior THA did not have a statistically significant impact on SSI rate (P=.42). There was also no difference in SSI, readmission, or reoperation in the high-risk group. The goal of using an incisional negative pressure wound therapy device is to help further decrease the risk of SSI. This study's findings suggest that the SSI rate in this group did not differ from that in the standard dressing group, such that the prophylactic use of a negative pressure wound therapy device is not indicated for either standard or high-risk patients undergoing primary anterior approach THA. [Orthopedics. 2019; 42(6):e539-e544.].

Total hip arthroplasty following illicit drug abuse

BACKGROUND

The role of illicit drug abuse in total joint arthroplasty is largely unknown and is likely underestimated. Patients with drug addictions often suffer from septic osteoarthritis or a necrosis of the femoral head. Purpose of the study was to evaluate the operative management and clinical outcome of total hip replacement in patients with a history of intravenous drug abuse.

METHODS

This retrospective study included 15 patients with a history of intravenous drug abuse who underwent total hip arthroplasty. A total of 6 females and 9 males with an average age of 34.3 years were identified. Ten patients presented an acute bacterial coxitis (Coxitis-group) and five an aseptic osteonecrosis of the femoral head (Osteonecrosis-group).

RESULTS

Ten patients with a bacterial coxitis underwent a two-staged total hip arthroplasty (THA), with temporary insertion of a drug-eluting spacer. Five patients with a necrosis of the femoral head were primarily treated with THA. All patients developed multiple re-infections after insertion of a drug-eluting spacer or THA. Only two patients finally achieved a THA without infection in the period of 3.9 years follow-up. The other 13 patients underwent a Girdlestone arthroplasty (7 patients) or total joint replacement with a chronic fistula (6 patients).

CONCLUSION

THA in patients with illicit drug abuse shows a low success rate. Following septic osteoarthritis or osteonecrosis in drug-addicted patients, we recommend a two-stage procedure with temporary insertion of a drug-eluting spacer. THA might follow only under strict premises.

The terminal complement pathway is activated in septic but not in aseptic shoulder revision arthroplasties

BACKGROUND

The early diagnosis of suspected periprosthetic low-grade infections in shoulder arthroplasties is important for the outcome of the revision surgical procedures. The aim of this study was to investigate new biomarkers of infection in revision shoulder arthroplasties, taking into account the implant design, patient age, and comorbidities.

METHODS

The study included 33 patients with shoulder arthroplasties undergoing revision surgical procedures. Microbiological diagnostic testing was performed in all cases. C-reactive protein serum levels and white blood cell counts were evaluated, and the periprosthetic tissue was stained immunohistologically for the terminal complement pathway components (C3, C5, and C9) and for CD68 and α-defensin.

RESULTS

Microbiological diagnostic testing detected a periprosthetic infection in 10 reverse shoulder arthroplasties and in 4 anatomic shoulder arthroplasties, while the remaining 19 shoulder arthroplasties were classified as aseptic. We observed more Staphylococcus epidermidis infections in reverse shoulder arthroplasties and more Staphylococcus aureus infections in anatomic shoulder arthroplasties. The revision rate correlated with pre-existing comorbidities and number of previous surgical procedures. The C-reactive protein values and the incidence of specific periprosthetic radiolucent lines were significantly increased in septic revision cases. We found increased staining for all tested complement factors (C3, C5, and C9) but not for α-defensin and CD68 in septic tissue. The most interesting finding was that C9 separated septic from aseptic tissue with a predictive specificity of 100% and a sensitivity of 88.89%.

CONCLUSION

We observed a strong correlation between C9 expressions in septic revision tissue. We propose that the terminal complement pathway, especially C9 deposition, may be a potential biomarker to identify septic complications using tissue biopsy specimens.

The Impact of Common Urologic Complications on the Risk of a Periprosthetic Joint Infection

BACKGROUND

Periprosthetic infections after total hip arthroplasty (THA) or total knee arthroplasty (TKA) are substantial complications, and there are conflicting reports of their association with urologic complications. Our objective was to determine whether urinary tract infection (UTI) and acute urinary retention (AUR) are significant risk factors for joint infections after THA or TKA.

METHODS

We performed a population-based, retrospective cohort study of patients who were ≥66 years old when they underwent an initial THA or TKA between April 2003 and March 2013. Investigated exposures included a UTI presenting for treatment within 2 years after joint replacement, as well as AUR within 30 days after THA or TKA. The primary outcome was joint infection requiring hospital admission following THA or TKA (which had to occur within 2.25 years after THA or TKA for the UTI exposure or 120 days for the AUR exposure).

RESULTS

A total of 113,061 patients met the inclusion criteria and had arthroplasties (44,495 THAs and 68,566 TKAs) during the study period. The median age was 74 years (interquartile range [IQR], 70 to 79 years). Of those patients, 28,256 (25.0%) had at least 1 UTI and they were more likely to be older and female; to have had previous antibiotic exposure, cystoscopy, or urinary retention; and to have atrial fibrillation. Most of those UTIs were coded as nonspecific UTI, and the patient was seen for outpatient treatment in a non-emergency department setting. A total of 2,516 patients (2.2%) had AUR within 30 days of the procedure. Those patients were more likely to be older and male, to have medical comorbidities, to have had previous transurethral procedures or cystoscopy and previous urology visits, and to have received a general anesthetic during their procedure. A total of 1,262 patients (1.1%) had joint infection requiring hospital admission. In multivariate Cox regression analysis, UTI was associated with an increased risk of joint infection (hazard ratio [HR], 1.21 [95% confidence interval (CI), 1.14 to 1.28]; p < 0.01). However multivariate analysis did not demonstrate an association between AUR and joint infection (HR, 0.99 [95% CI, 0.60 to 1.64]; p = 0.98).

CONCLUSIONS

UTI was associated with increased risk of hip or knee periprosthetic joint infection, whereas AUR was not a significant risk factor. Timely and appropriate treatment of symptomatic UTIs in this patient population may be important to prevent periprosthetic joint infection.

LEVEL OF EVIDENCE

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

Development and Evaluation of a Prognostic Calculator for the Surgical Treatment of Periprosthetic Joint Infection

BACKGROUND

Preoperative identification of patients at risk of failing surgical treatment for periprosthetic joint infection (PJI) is imperative to allow medical optimization and targeted prevention. The purpose of this study was to create a preoperative prognostic calculator for PJI treatment by assessing a patient's individual risk for treatment failure based on many preoperative variables.

METHODS

A retrospective review was performed of 1438 PJIs, treated at 2 institutions from 2000 to 2014. Minimum follow-up was 1 year. A total of 63 risk factors, including patient characteristics, microbiology data, and surgical variables were evaluated using logistic regression, in which coefficients were scaled to produce weighted scores.

RESULTS

The 10 significant risk factors for PJI treatment failure were in descending order of relative weight: irrigation and debridement (30 points), history of myocardial infarction (15 points), revision surgery (11 points), presence of sinus tract (10 points), resistant organisms (9 points), ever smoker (6 points), prior surgery (2.86 points per prior operation), synovial white blood cell count (8.3 × natural log of cell count), body mass index (0.66 per increment), and erythrocyte sedimentation rate (depends on both smoking and 2 stage, as these are higher order interaction factors). The area under the curve for this risk model was 0.6904 (95% confidence interval: 0.6476-0.7331).

CONCLUSION

In this large cohort study, we were able to identify risk factors and their relative weight for predicting PJI treatment failure. Some of the identified factors are indeed modifiable and should be addressed before treating a patient for PJI.

Postoperative Blood Glucose Levels Predict Infection After Total Joint Arthroplasty

BACKGROUND

Perioperative hyperglycemia has many etiologies, including medication, impaired glucose tolerance, uncontrolled diabetes mellitus, or stress, the latter of which is common in patients postoperatively. Our study investigated the influence of postoperative blood glucose levels on periprosthetic joint infection after elective total joint arthroplasty to determine a threshold for glycemic control for which surgeons should strive during a patient's hospital stay.

METHODS

A single-institution retrospective review was conducted on 24,857 primary total joint arthroplasties performed from 2001 to 2015. Of these, 13,196 had a minimum follow-up of 1 year (mean, 5.9 years). Postoperative day 1 morning blood glucose levels were utilized and were correlated with periprosthetic joint infection, as defined by the International Consensus Group on Periprosthetic Joint Infection. Multivariable analysis was used to determine the influence of several important covariates on infection. An alpha level of 0.05 was used to determine significance.

RESULTS

The rate of periprosthetic joint infection increased linearly from blood glucose levels of ≥115 mg/dL. Multivariable analysis revealed that blood glucose levels were significantly associated with periprosthetic joint infection (p = 0.028). The optimal blood glucose threshold to reduce the likelihood of periprosthetic joint infection was 137 mg/dL. The periprosthetic joint infection rate in the entire cohort was 1.59% (1.46% in patients without diabetes compared with 2.39% in patients with diabetes; p = 0.001). There was no significant association between blood glucose level and periprosthetic joint infection in patients with diabetes (p = 0.276), although there was a linear trend.

CONCLUSIONS

The relationship between postoperative blood glucose levels and periprosthetic joint infection increased linearly, with an optimal cutoff of 137 mg/dL. Immediate and strict postoperative glycemic control may be critical in reducing postoperative complications, as even mild hyperglycemia was significantly associated with periprosthetic joint infection.

LEVEL OF EVIDENCE

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

Effects of fondaparinux on wound drainage after total hip and knee arthroplasty

Background

The purpose of this investigation was to determine the effects of fondaparinux on postoperative wound drainage, length of hospital stay (LOS) and rate of surgical site infection in total joint patients.

Methods

117 patients undergoing total joint arthroplasty treated with fondaparinux for venous thromboembolism (VTE) prophylaxis were prospectively studied.

Results

The average time to a dry wound was 3.4 days, with an average LOS of 3.77 days. Perioperative complications included 2 cases each of superficial cellulitis, deep vein thrombosis, and pulmonary embolism; there were no cases of deep infection. Multi-variate analysis showed increased patient BMI increased LOS (p = 0.0169).

Conclusion

Fondaparinux is an effective drug for VTE prophylaxis in total joint arthroplasty with wound drainage and LOS comparable to historical controls of enoxaparin, warfarin, and rivaroxaban.

[Prevention of postoperative infections : Risk factors and the current WHO guidelines in musculoskeletal surgery]

BACKGROUND

Despite the many scientific and technological advances postoperative infection continues to be a large problem for trauma and orthopedic surgeons. Based on a review of the current literature, this study provides a comprehensive overview of the risk factors (RF) and possible preventive measures to control surgical site infections.

METHODS

Medline search and analysis from 1968-2017 (as of 01 March 2017). Selection of trauma and orthopedic relevant RFs and comparison with WHO recommendations (global guidelines for the prevention of surgical site infection, Nov. 2016).

RESULTS

Identification of 858 relevant articles from the last 50 years (1968-2017). Pooled postoperative rate of infection is 0.3% (hand surgery) and 19% (3rd degree open fractures). For open fractures, there is no clear tendency towards lower infection rates during the past five decades. Identification of 115 RF from three areas (patient-dependent RF, organizational and procedural RF, trauma- and surgery-dependent RF). The five most important RFs are body mass index over 35 kg/m², increased duration of surgery, diabetes mellitus, increased blood glucose levels in the perioperative period also in the case of nondiabetic patients, and errors in the perioperative antibiotic prophylaxis.

DISCUSSION

Inconsistent definition of "infection", interaction of the RF and the different follow-up duration limit the meaningfulness of the study.

CONCLUSION

In the future, considerable efforts must be made in order to achieve a noticeable reduction in the rate of infection, especially in the case of high-risk patients.

Managing an Acute and Chronic Periprosthetic Infection

A case report of a 65-year-old female with a history of right total hip arthroplasty (THA) in 2007 and left THA in 2009 was presented. She consulted with our institution for the first time, on December 2013, for right hip pain and fistula on the THA incision. It was managed as a chronic infection, so a two-stage revision was performed. First-time intraoperative cultures were positive for Staphylococcus aureus (3/5) and Proteus mirabilis (2/5). Three weeks after the second half of the review, it evolved with acute fever and pain in relation to right hip. No antibiotics were used, arthrocentesis was performed, and a coagulase-negative staphylococci multisensible was isolated at the 5th day. Since the germ was different from the first revision, it was decided to perform a one-stage revision. One year after the first review, the patient has no local signs of infection and presents ESV and RPC in normal limits. The indication and management of periprosthetic infections are discussed.

Distal radius re-fracture with bending of implant and neurovascular compromise

Peri-implant fractures of the wrist are uncommon, and usually present as stress fractures distal to the site of the implant. We report an unusual case where the radius has fractured beneath a plate, causing bending and deformity of the implant. This prevented reduction of the fracture under sedation, so urgent intervention became necessary due to neurovascular compromise.

Chronic kidney disease is associated with a risk of higher mortality following total knee arthroplasty in diabetic patients: a nationwide population-based study

Diabetes and chronic kidney disease (CKD) are associated with a higher rate of complications in patients undergoing total knee arthroplasty (TKA). The purpose of this study was to determine the effects of CKD and diabetes in patients after TKA. Diabetic patients who received unilateral primary TKA between January 2008 and December 2011 were enrolled. The follow-up period was more than 6 months. The primary outcome was a TKA-related infection and the secondary outcome was all-cause mortality. The study cohort included 13844 patients who were followed for a mean period of 2 years, of whom 1459 (10.5%) had CKD. The patients with CKD were older than those without CKD (71.6 versus 70.3 years, P<0.0001) and had higher rates of hypertension, gouty arthritis, ischemic heart disease, chronic pulmonary obstructive disease, pulmonary embolism and deep vein thrombosis (all P<0.0001). After adjustment of comorbidities, the CKD group had a higher incidence of urinary tract infections (OR: 1.61, 95% CI: 1.19-2.17). There were no significant differences in wound infections, pneumonia, pulmonary embolism or in-hospital death between the two groups. After adjustment of confounders, the CKD group had higher rates of myocardial infarction (HR: 2.06, 95% CI: 1.26–3.39) and mortality (HR: 1.99, 95% CI: 1.59–2.48). The risk of TKA-related infection during follow-up was comparable between the two groups (HR: 1.31, 95% CI: 0.94–1.82). In conclusion, CKD is associated with increased risks of urinary tract infections, myocardial infarction and all-cause mortality after TKA. Surgeons should be aware of this when evaluating TKA patients with renal disease.

Understanding biomaterial-tissue interface quality: combined in vitro evaluation

One of the greatest challenges in the development of new medical products and devices remains in providing maximal patient safety, efficacy and suitability for the purpose. A 'good quality' of the tissue-implant interface is one of the most critical factors for the success of the implant integration. In this paper this challenge is being discussed from the point of view of basic stimuli combination to experimental testing. The focus is in particular on bacterial effects on tissue-implant interaction (for different materials). The demonstration of the experimental evaluation of the tissue-implant interface is for dental abutment with mucosal contact. This shows that testing of the interface quality could be the most relevant in controlled conditions, which mimic as possible the clinical applications, but consider variables being under the control of the evaluator.

Two-stage revision after total knee arthroplasty

BACKGROUND AND AIM OF THE WORK

Periprosthetic knee infection is a complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5,6% in revisions; incidence is increasing over the years. Two-stage revision is the technique used in chronic infection. Aim of the work is to check success rate in our data. Methods. We analyzed retrospectively data of patients who undergone two stage revision surgery between 01/01/2010 to 31/12/2015. We made a clinical and radiological control after 1, 3, 6, 12, 24 months and we evaluate the outcome in December 2016. Results. Between 2010 and 2015 we treated 45 patients with two-stage revision. Mean follow-up was 3,4 years. Success rate is 89,9%. We had failure in 5 patients: everyone had knee surgery before first knee arthroplasty and Charlson Comorbidity Score was greater then 4 in 4 cases. Conclusions. Two stage revision can be considered a successful treatment in chronic periprosthetic knee infection. It has an optimal success rate, but it has some disadvantages as joint stiffness and pain in the interval between stages. This is a technique with two major surgery procedure with associated morbidity, discomfort, cost and prolonged stay in hospital.

[Periprosthetic infections in patients with rheumatism : A challenge]

The increasing number of implantations will lead to more periprosthetic infections. Periprosthetic infections in patients with rheumatism, who are often undergoing immunosuppressive treatment, represent a challenge for the treating physicians. The optimal care and treatment therefore necessitate an interdisciplinary agreement between orthopedic surgeons, specialists for infections and rheumatologists.

Diagnosing Infection in Patients Undergoing Conversion of Prior Internal Fixation to Total Hip Arthroplasty

BACKGROUND

Criteria for diagnosis of infected internal fixation implants at the time of conversion to total hip arthroplasty (THA) are not clear. The purpose of this study is to identify risk factors for infection in patients undergoing conversion to THA.

METHODS

We retrospectively reviewed patients at a single institution who underwent conversion to THA from 2009 to 2014. Patients were diagnosed with infection preoperatively using Musculoskeletal Infection Society criteria or postoperatively if they were found to have positive cultures intraoperatively at the time of conversion surgery. Medical comorbidities and preoperative inflammatory markers were compared between infected and noninfected groups. Univariate and multivariate logistic regression analysis were performed to identify independent risk factors for infection. Receiver operating characteristic curves were generated to determine test performance of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A post hoc power analysis was performed.

RESULTS

Thirty-three patients were included in the study. Six patients (18%) were diagnosed with infection. We found no association between comorbidities and infection in this cohort. The mean ESR and CRP were higher in infected (ESR = 41.6 mm/h, CRP = 2.0 mg/dL) vs noninfected (ESR = 19.3 mm/h, CRP = 1.3 mg/dL) groups (both P < .01). ESR >30 mm/h (odds ratio 28.8, 95% confidence interval 2.6-315.4, P = .001) and CRP >1.0 mg/dL (odds ratio 11.5, 95% confidence interval 1.6-85.2, P = .01) were strongly associated with infection. Receiver operating characteristic curves for ESR (area under the curve [AUC] = 0.89) and CRP (AUC = 0.89) demonstrated good fit.

CONCLUSION

We report a high incidence of infection in patients who underwent conversion to THA. Preoperative ESR and CRP are effective screening tools though occult infections may still be missed. Patients with borderline or elevated inflammatory markers should raise strong suspicion for infection.

Risk Factors for Perimegaprosthetic Infections After Tumor Resection

Periprosthetic joint infection remains one of the most challenging and pervasive complications following megaprosthetic replacement after tumor resection. The authors conducted a systematic review of the literature for clinical studies that reported a risk factor analysis for perimegaprosthetic joint infections. The search included English-language studies published up to July 2015. Eight studies fulfilled the inclusion criteria. Identified factors mostly related to both surgical procedure and hospitalization. Physicians should consider these results when discussing the outcomes of limb salvage surgery with patients and trying to reduce the overall burden of perimegaprosthetic joint infections. [Orthopedics. 2017; 40(1):e11-e16.].

Two-stage revision after total knee arthroplasty

Background and aim of the work: Periprosthetic knee infection is a complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5,6% in revisions; incidence is increasing over the years. Two-stage revision is the technique used in chronic infection. Aim of the work is to check success rate in our data. Methods: We analyzed retrospectively data of patients who undergone two stage revision surgery between 01/01/2010 to 31/12/2015. We made a clinical and radiological control after 1, 3, 6, 12, 24 months and we evaluate the outcome in December 2016. Results: Between 2010 and 2015 we treated 45 patients with two-stage revision. Mean follow-up was 3,4 years. Success rate is 89,9%. We had failure in 5 patients: everyone had knee surgery before first knee arthroplasty and Charlson Comorbidity Score was greater then 4 in 4 cases. Conclusions: Two stage revision can be considered a successful treatment in chronic periprosthetic knee infection. It has an optimal success rate, but it has some disadvantages as joint stiffness and pain in the interval between stages. This is a technique with two major surgery procedure with associated morbidity, discomfort, cost and prolonged stay in hospital. (www.actabiomedica.it)

Should We Think Twice About Psychiatric Disease in Total Hip Arthroplasty?

BACKGROUND

Psychiatric disease (PD) is common, and the effect on complications in total hip arthroplasty (THA) is poorly understood. The purpose of this study was to evaluate the medical and surgical postoperative complication profile in patients with PD, and we hypothesize that they will be significantly increased compared with control group.

METHODS

A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease version 9 codes to identify 86,976 patients who underwent primary THA with PD including bipolar (5626), depression (82,557), and schizophrenia (3776). A cohort of 590,689 served as a control with minimum 2-year follow-up. Medical and surgical complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts.

RESULTS

Patients with PD were more likely to be younger (age < 65 years; odds ratio [OR] = 4.51, P < .001), female (OR = 2.02, P < .001) and more medically complex (significant increase in 28/28 Elixhauser medical comorbidities, P < .001). There was a significant increase (P < .001) in 13/14 (92.8%) recorded postoperative medical complications rates at the 90-day time point. In addition, there was a statistically significant increase in periprosthetic infection (OR = 2.26, P < .001), periprosthetic fracture (OR = 2.09, P < .001), dislocation (OR = 2.30, P < .001), and THA revision (OR = 1.93, P < .001) at overall follow-up.

CONCLUSION

Patients with PD who undergo elective primary THA have significantly increased medical and surgical complication rates in the global period and short-term follow-up, and these patients need to be counseled accordingly.