Robotics and Navigation Do Not Affect the Risk of Periprosthetic Joint Infection Following Primary Total Hip Arthroplasty: A Propensity Score-Matched Cohort Analysis

BACKGROUND

The use of computer navigation or robotic assistance during primary total hip arthroplasty (THA) has yielded numerous benefits due to more accurate component positioning. The utilization of these tools is generally associated with longer operative times and also necessitates additional surgical equipment and personnel in the operating room. Thus, the aim of this study was to evaluate the impact of technology assistance on periprosthetic joint infection (PJI) after primary THA.

METHODS

We retrospectively reviewed the records for 12,726 patients who had undergone primary THA at a single high-volume institution between 2018 and 2021. Patients were stratified by surgical technique (conventional THA, computer-navigated THA [CN-THA], or robotic-assisted THA [RA-THA]) and were matched 1:1 with use of propensity score matching. Univariate and logistic regression analyses were performed to compare the rates of PJI within 90 days postoperatively between the cohorts.

RESULTS

After propensity score matching, there were 4,006 patients in the THA versus RA-THA analysis (2,003 in each group) and 5,288 patients in the THA versus CN-THA analysis (2,644 in each group). CN-THA (p < 0.001) and RA-THA (p < 0.001) were associated with longer operative times compared with conventional THA by 3 and 11 minutes, respectively. The rates of PJI after conventional THA (0.2% to 0.4%) were similar to those after CN-THA (0.4%) and RA-THA (0.4%). On the basis of logistic regression, the development of PJI was not associated with the use of computer navigation (odds ratio [OR], 1.8 [95% confidence interval (CI), 0.7 to 5.3]; p = 0.232) or robotic assistance (OR, 0.9 [95% CI, 0.3 to 2.3]; p = 0.808).

CONCLUSIONS

Despite longer operative times associated with the use of computer navigation and robotic assistance, the use of these tools was not associated with an increased risk of PJI within 90 days after surgery.

LEVEL OF EVIDENCE

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

Validation of the Incidence of Reported Periprosthetic Joint Infections in Total Hip and Knee Arthroplasty in the Dutch Arthroplasty Register

BACKGROUND

Arthroplasty registers underreport the incidence of periprosthetic joint infections (PJIs). We validated the incidence of reported PJIs in total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in the Dutch Arthroplasty Register (LROI) using data from the Dutch National Nosocomial Surveillance Network (PREZIES).

METHODS

All primary THAs and TKAs from the LROI and all primary THAs and TKAs performed in consenting hospitals from PREZIES between 2012 and 2018 were matched on date of birth, date of surgery, sex, hospital, and type of procedure (THA n = 91,208; TKA n = 80,304). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for PJIs registered in the LROI, using PREZIES as a reference.

RESULTS

The incidence of registered PJIs in THAs was 1.2% in PREZIES and 0.5% in the LROI. For TKAs, this was 0.7 and 0.4%, respectively. The PJIs in THAs in the LROI had a sensitivity of 0.32 (confidence interval [CI]: 0.29 to 0.35), specificity of 1.00 (CI: 1.00 to 1.00), PPV of 0.74 (CI: 0.70 to 0.78), and NPV of 0.99 (CI: 0.99 to 0.99). In TKAs, the sensitivity, specificity, PPV, and NPV were 0.38 (CI: 0.34 to 0.42), 1.00 (CI: 1.00 to 1.00), 0.65 (CI: 0.59 to 0.70), and 1.00 (CI: 1.00 to 1.00), respectively.

CONCLUSIONS

The LROI captures approximately one-third of the PJIs as revision within one year for infection or resection arthroplasty. The capture rate of PJIs can be improved by including all reoperations without component exchange and nonsurgical treatments with antibiotics only.

Preoperative dental screening can reduce periprosthetic infections of hip and knee endoprostheses in the first month after surgery: results of a cohort study

PURPOSE

The oral cavity and, in particular, potential oral foci might pose a risk of periprosthetic joint infection (PJI). The aim of this cohort study was to determine whether practical preoperative dental screening would reduce the prevalence of early PJI in the first month after surgery.

METHODS

Patients attending a specialized endoprosthesis implantation clinic between 2018 and 2022 were recruited. Two groups were examined. The test group consisted of patients attending the clinic between 2020 and 2022 and who were referred to their family dentist using a standardized form. The comparison group consisted of patients who were treated in the clinic between 2018 and 2020. They were not referred to their family dentist. The two groups were compared for the prevalence of PJI. Univariate analysis followed by multiple logistic regression was performed to confirm risk factors for PJI in this cohort.

RESULTS

2560 individuals (test group: 1227, comparison group: 1333) were included. The prevalence of PJI was significantly lower in the test group (0.8% vs. 1.8%, p = 0.04). Multiple logistic regression with PJI as the dependent variable showed that a dental referral was a strong predictor of a lower prevalence of PJI (OR: 0.43, CI95 0.205-0.917, p = 0.03). Male gender was also strongly associated with a higher frequency of PJI (OR: 2.68, CI95 1.32-5.42, p = 0.01). Age (OR: 1.06, CI95 1.01-1.10, p = 0.01) and BMI (OR: 1.11, CI95 1.05-1.17, p < 0.01) had little effect on the risk of PJI.

CONCLUSION

Dental referral using a standardized form can reduce the prevalence of early PJI. Accordingly, orthopedists and dentists should collaborate in this practical way.

Evaluation of time to reimplantation as a risk factor in two-stage revision with static spacers for periprosthetic knee joint infection

INTRODUCTION

We investigated the time to reimplantation (TTR) during two-stage revision using static spacers with regard to treatment success and function in patients with chronic periprosthetic joint infection (PJI) of the knee.

METHODS

163 patients (median age 72 years, 72 women) who underwent two-stage exchange for chronic knee PJI between 2012 and 2020 were retrospectively analyzed (based on the 2011 Musculoskeletal Infection Society criteria). A cutoff TTR for increased risk of reinfection was identified using the maximally selected log-rank statistic. Infection control, aseptic revisions and overall survival were analyzed using Kaplan-Meier survival estimates. Adjustment for confounding factors-the Charlson Comorbidity Index (CCI) and C-reactive protein (CRP)-was done with a Cox proportional hazards model.

RESULTS

When TTR exceeded 94 days, the adjusted hazard of reinfection was increased 2.8-fold (95% CI 1.4-5.7; p = 0.0036). The reinfection-free rate was 67% (95% CI 52-79%) after 2 years and 33% (95% CI 11-57%) after 5 years for a longer TTR compared to 89% (95% CI 81-94%) and 80% (95% CI 69-87%) at 2 and 5 years, respectively, for a shorter TTR. Adjusted overall survival and number of aseptic revisions did not differ between the longer TTR and shorter TTR groups. Maximum knee flexion was 90° (IQR 84-100) for a longer TTR and 95° (IQR 90-100) for a shorter TTR (p = 0.0431), with no difference between the groups in Oxford Knee Score. Baseline characteristics were similar (body mass index, age, previous surgeries, microorganisms) for the two groups, except that there was a higher CCI (median 4 vs. 3) and higher CRP (median 3.7 vs 2.6 mg/dl) in the longer TTR group.

CONCLUSION

A long TTR is sometimes unavoidable in clinical practice, but surgeons should be aware of a potentially higher risk of reinfection.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Chronic infective arthritis with osteomyelitis of the ankle due to Pseudomonas aeruginosa infection in a middle-age woman: A rare causative pathogen requiring vigilance

RATIONALE

Pseudomonas aeruginosa-induced septic arthritis is a relatively uncommon phenomenon. It has been documented in children with traumatic wounds, young adults with a history of intravenous drug use, and elderly patients with recent urinary tract infections or surgical procedures.

PATIENT CONCERNS

Fifty-nine year-old female had no reported risk factors. The patient sought medical attention due to a 6-month history of persistent pain and swelling in her right ankle.

DIAGNOSES

Magnetic resonance imaging and a 3-phase bone scan revealed findings suggestive of infectious arthritis with concurrent osteomyelitis. Histopathological examination of the synovium suggested chronic synovitis, and synovial tissue culture confirmed the presence of P aeruginosa.

INTERVENTION

Arthroscopic synovectomy and debridement, followed by 6 weeks of targeted antibiotic therapy for P aeruginosa.

OUTCOMES

Following treatment, the patient experienced successful recovery with no symptom recurrence, although she retained a mild limitation in the range of motion of her ankle.

LESSONS

To our knowledge, this is the first reported case of chronic arthritis and osteomyelitis caused by P aeruginosa in a patient without conventional risk factors. This serves as a crucial reminder for clinicians to consider rare causative organisms in patients with chronic arthritis. Targeted therapy is imperative for preventing further irreversible bone damage and long-term morbidity.

Bone and joint infection complicated with sepsis in neonates and infants under three months of age

OBJECTIVE

Studies focusing on bone and joint infections (BJIs) in young infants are rare. Some cases of BJI are accompanied by sepsis. This study aimed to identify the clinical and bacteriological features of sepsis in neonates and young infants with BJIs.

METHODS

Neonates and infants younger than 3 months diagnosed with BJI in the present institution from 2014 to 2021 were retrospectively reviewed. Patient characteristics, clinical data, and outcomes were documented and compared between those with and without sepsis.

RESULTS

Twenty-five patients with a mean age of 34.8 days were included. Nine BJI cases had concomitant sepsis (group A), and 16 had BJI without sepsis (group B). Within group A, staphylococcus aureus was the major pathogenic germ (5 cases, of which 4 were of the methicillin-resistant staphylococcus aureus (MRSA) type). There was no statistical difference in male-to-female ratio, age, history of hospitalization, anemia, birth asphyxia, peripheral leukocyte counts, C-reactive protein on admission, and sequelae between groups. Univariate analyses indicated a significant difference in the incidence of septic arthritis (SA) combined with osteomyelitis (OM) (88.9% vs 37.5%), congenital deformities (44.4% vs 0%), and mean duration of symptoms (2.83 days vs 9.21 days) in comparisons between groups A and B.

CONCLUSION

Staphylococcus aureus is the main pathogenic bacteria in BJI cases complicated with sepsis in neonates and young infants. Among infants younger than 3 months diagnosed with BJI, those with concurrent SA and OM, MRSA infection, or congenital deformities are more likely to develop sepsis.

Semaglutide Use Prior to Total Hip Arthroplasty Results in Fewer Postoperative Prosthetic Joint Infections and Readmissions

BACKGROUND

Semaglutide, a novel diabetes management medication, is known for its efficacy in inducing weight loss. Despite this, its impact on outcomes after total hip arthroplasty (THA) remains unclear. The aim of this study was to evaluate if THA patients on semaglutide demonstrate: (1) fewer medical complications; (2) fewer implant-related complications; (3) fewer readmissions; and (4) lower costs.

METHODS

Using a national claims database from 2010 to 2021, we retrospectively examined diabetic patients prescribed semaglutide who underwent primary THA. This yielded 9,465 patients (Semaglutide = 1,653; Control = 7,812). Multivariable logistic regression was used to evaluate the following outcomes: 90-day postoperative medical complications, 2-year implant-related complications, 90-day readmissions, in-hospital lengths of stay, and day-of-surgery and 90-day episode of care costs.

RESULTS

Semaglutide users exhibited lower 90-day readmission rates (6.2 versus 8.8%; odds ratio 0.68; P < .01) and reduced prosthetic joint infections (1.6 versus 2.9%; odds ratio 0.56; P < .01). However, medical complication rates, hospital stays, same-day surgical costs, and 90-day episode costs showed no significant differences.

CONCLUSIONS

This study highlights semaglutide users undergoing THA with fewer 90-day readmissions and 2-year prosthetic joint infections. Although no variance appeared in medical complications, hospital stays, or costs, the medication's notable glycemic control and weight loss benefits could prompt pre-surgery consideration. Further research is essential for a comprehensive understanding of semaglutide's impact on post-THA outcomes.

Higher Blood Glucose Levels on the Day of Surgery Are Associated with an Increased Risk of Periprosthetic Joint Infection After Total Hip Arthroplasty

BACKGROUND

Hyperglycemia has been identified as a risk factor for periprosthetic joint infection (PJI) after total hip arthroplasty (THA). However, there is no consensus with regard to the preoperative blood glucose level (BGL) on the day of the surgical procedure associated with increased risk. We sought to identify preoperative BGL thresholds associated with an increased risk of PJI.

METHODS

The Premier Healthcare Database was retrospectively queried for adult patients who underwent primary, elective THA and had a measurement of the preoperative BGL recorded on the day of the surgical procedure (preoperative BGL) from January 1, 2016, to December 31, 2021. The association between preoperative BGL and 90-day PJI risk was modeled using multivariable logistic regression with restricted cubic splines. Patients with and without diabetes with a preoperative BGL associated with 1.5 times greater odds of PJI (high preoperative BGL) were then compared with patients with a normal preoperative BGL.

RESULTS

In this study, 90,830 patients who underwent THA and had a recorded preoperative BGL were identified. The preoperative BGL associated with 1.5 times greater odds of PJI was found to be 277 mg/dL in patients with diabetes and 193 mg/dL in patients without diabetes. Compared with the normal preoperative BGL cohort, those with high preoperative BGL had increased odds of PJI (adjusted odds ratio [OR], 2.60 [95% confidence interval (CI), 1.45 to 4.67] for patients with diabetes and 1.66 [95% CI, 1.10 to 2.51] for patients without diabetes) and 90-day readmissions (adjusted OR, 1.92 [95% CI, 1.45 to 2.53] for patients with diabetes and 1.66 [95% CI, 1.37 to 2.00] for patients without diabetes).

CONCLUSIONS

Increased preoperative BGL was found to be associated with an increased risk of PJI following primary THA. Surgeons should be aware of patients with diabetes and a preoperative BGL of >277 mg/dL and patients without diabetes but with a preoperative BGL of >193 mg/dL.

LEVEL OF EVIDENCE

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

Surgical correction of neonatal obstructive sleep apnea due to a temporomandibular joint ankylosis

In growing children, temporomandibular joint (TMJ) ankylosis and septic arthritis are uncommon. Retrognathia and micrognathia affect airway patency and can cause obstructive sleep apnea (OSA). No unified diagnostic criteria have been established for the management of this pathology. We describe the first case of treatment for pediatric TMJ ankylosis and severe OSA due to neonatal group B streptococcal septic TMJ arthritis. Untreated pathological changes in the TMJ will eventually lead to ankylosis. Among children, this will include facial growth disturbances leading to mandibular retrognathia, reduction in the oropharyngeal spaces, and OSA. Our patient had severe OSA with an apnea-hypopnea index of 24.9 events/h and oxygen saturation nadir of 73% as measured by polysomnography. She was treated successfully according to Andrade protocol. This is the first report of pediatric OSA due to TMJ ankylosis following neonatal group B streptococcal septic arthritis.

CITATION

Pesis M, Goldbart A, Givol N. Surgical correction of neonatal obstructive sleep apnea due to a temporomandibular joint ankylosis. J Clin Sleep Med. 2024;20(1):173-179.

Unreliability of Serum- or Plasma-based Assays of D-dimer or Fibrin (Fibrinogen) Degradation Product for Diagnosing Periprosthetic Joint Infection: A Prospective Parallel Study

OBJECTIVE

The ability of D-dimer to diagnose periprosthetic joint infection (PJI) before revision hip or knee arthroplasty is still controversial, and the differences in diagnostic ability between serum- or plasma-based assays of D-dimer and fibrin (fibrinogen) degradation product (FDP) are uncertain. The prospective parallel study was performed to determine the ability of D-dimer to diagnose PJI before revision hip or knee arthroplasty, and the differences in diagnostic ability between serum- or plasma-based assays of D-dimer and FDP.

METHODS

Patients undergoing knee or hip arthroplasty at our institution were prospectively enrolled into the following groups: those without inflammatory diseases who were undergoing primary arthroplasty ("Prim" group), those with inflammatory arthritis who were undergoing primary arthroplasty ("Prim/Inflam"), those undergoing revision arthroplasty because of aseptic failure ("Rev/Asept"), or those undergoing revision arthroplasty because of PJI ("Rev/PJI"). The ability of preoperative levels of D-dimer or FDP in serum or plasma to diagnose PJI in each group was assessed using areas under receiver operating characteristic curves (AUCs) and other diagnostic performance indicators. The diagnostic performance of these assays was compared with that of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

RESULTS

In the final analysis, Prim included 42 patients; Prim/Inflam, 40; Rev./Asept, 62; and Rev./PJI, 47. D-dimer assays led to AUCs of 0.635 in serum and 0.573 in plasma, compared to 0.593 and 0.607 for FDP. Even in combination with CRP or ESR, these assays failed to perform as well as the combination of CRP and ESR for diagnosing PJI.

CONCLUSION

Levels of D-dimer or FDP in serum or plasma, whether used alone or together with CRP or ESR, are unreliable for diagnosing PJI before revision arthroplasty.

Organism profile and C-reactive protein (CRP) response are different in periprosthetic joint infection in patients with hepatitis

PURPOSE

Hepatitis B and C are important and relatively common health issues. It is known that many patients who underwent total knee and hip arthroplasty were also diagnosed with hepatitis. These patients are at higher risk of periprosthetic joint infection (PJI). This study aimed to investigate the differences in PJI cases in hepatitis B and C patients.

METHODS

This is a retrospective case-controlled single-center study. A total of 270 patients with hepatitis and non-hepatitis (control group) who underwent one-stage septic exchange to the hip and knee joints were included in the study. All patients' previous surgical histories, infective organisms, C-reactive protein (CRP) values before septic exchange, and demographic data were evaluated. All microbiological and laboratory evaluations were performed separately for knee and hip arthroplasty.

RESULTS

The mean CRP levels of Hep B- and C-positive patients, who underwent one-stage septic exchange in the knee joint, were 23.6 mg/L. In the control group, this value was 43.1 mg/L and a statistically significant difference was found between the groups (p = 0.004). Gram-negative organisms were identified in a larger proportion of patients with hepatitis who developed PJI in both hip and knee joints and underwent one-stage septic exchange (p = 0.041/p = 0.044).

CONCLUSION

PJIs caused by Gram-negative bacteria are encountered more frequently in patients with hepatitis than in the control group. In addition, the CRP rise is less in patients with hepatitis compared to PJI cases in the control group. Patient-specific evaluation is required in cases of PJI in patient groups with co-existing hepatitis.

A Pilot Observational Study Evaluating the Diagnostic Capacity of Rotational Thromboelastometry in Periprosthetic Joint Infections

BACKGROUND

Periprosthetic joint infections (PJIs) are associated with altered hemostatic dynamics; therefore, coagulation laboratory methods such as rotational thromboelastometry (ROTEM) may be valuable in their diagnosis. The aim of this study was to evaluate the diagnostic role of ROTEM in PJI.

METHODS

A diagnostic study was conducted including 65 patients who underwent revision total hip arthroplasty or total knee arthroplasty due to PJI (30 patients) or aseptic loosening (35 patients). Preoperative laboratory evaluation included conventional coagulation studies, inflammatory markers, and ROTEM analysis. These parameters were compared between patients with PJI and patients with aseptic loosening.

RESULTS

Several ROTEM parameters differed in the patients with PJI, indicating a higher coagulation potential associated with PJI. Specifically, the development of PJI was associated with higher EXTEM maximum clot firmness (MCF) (odds ratio [OR], 1.12 [95% confidence interval (CI), 1.04 to 1.20]; p = 0.001). Among the ROTEM parameters, EXTEM MCF was found to have the highest diagnostic accuracy for PJI (area under the receiver operating characteristic curve, 0.850; sensitivity, 76.6%; specificity, 91.4%), which was comparable with C-reactive protein (CRP) (p = 0.22) and erythrocyte sedimentation rate (ESR) (p = 0.65), but higher than D-dimer (p = 0.037). Moreover, the combined diagnostic accuracy of elevated EXTEM MCF and CRP was improved compared with CRP alone (p = 0.019).

CONCLUSIONS

Our results indicate that ROTEM analysis might be helpful for the detection of the hemostatic derangements that are associated with the development of PJI. However, because of the small size of this pilot study, further research is needed to investigate the value of incorporating viscoelastic studies in diagnostic scores for PJI.

LEVEL OF EVIDENCE

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

Elbow septic arthritis in an infant: an unusual presentation of invasive pneumococcal disease

Acute septic arthritis is a rare, potentially severe infection that requires immediate treatment to avoid long-term morbidity. Most common aetiological agents are commonly used for empirical treatment, but the choice of antibiotics may be influenced by other factors, such as the patient's age and the epidemiological context.We report an infant with elbow arthritis, whose treatment was changed after Streptococcus pneumoniae serotype 9N was isolated in the blood and synovial fluid. The child underwent arthrocentesis and received intravenous ampicillin followed by oral amoxicillin, with a favourable response and no sequelae at 1-year follow-up.We report an uncommon manifestation of invasive pneumococcal disease in a young immunised healthy infant caused by a non-vaccine serotype. The presence of S. pneumoniae should be considered in joint infections, especially in infants and those with a history of respiratory symptoms.

Body Mass Index and Revision Total Knee Arthroplasty: Does Cause for Revision Vary by Underweight or Obese Status?

BACKGROUND

Body mass index (BMI) impacts risk for revision total knee arthroplasty (rTKA), but the relationship between BMI and cause for revision remains unclear. We hypothesized that patients in different BMI classes would have disparate risk for causes of rTKA.

METHODS

There were 171,856 patients who underwent rTKA from 2006 to 2020 from a national database. Patients were classified as underweight (BMI < 19), normal-weight, overweight/obese (BMI 25 to 39.9), or morbidly obese (BMI > 40). Multivariable logistic regressions adjusted for age, sex, race/ethnicity, socioeconomic status, payer status, hospital geographic setting, and comorbidities were used to examine the effect of BMI on risk for different rTKA causes.

RESULTS

Compared to normal-weight controls, underweight patients were 62% less likely to undergo revision due to aseptic loosening, 40% less likely due to mechanical complications, 187% more likely due to periprosthetic fracture, 135% more likely due to periprosthetic joint infection (PJI). Overweight/obese patients were 25% more likely to undergo revision due to aseptic loosening, 9% more likely due to mechanical complications, 17% less likely due to periprosthetic fracture, and 24% less likely due to PJI. Morbidly obese patients were 20% more likely to undergo revision due to aseptic loosening, 5% more likely due to mechanical complications, and 6% less likely due to PJI.

CONCLUSION

Mechanical reasons were more likely to be the cause of rTKA in overweight/obese and morbidly obese patients, compared to underweight patients, for whom revision was more likely to be infection or fracture related. Increased awareness of these differences may promote patient-specific management to reduce complications.

LEVEL OF EVIDENCE

III.

Sequential pre-disinfection with chlorhexidine and alcohol reduces periprosthetic joint infection after primary knee arthroplasty: A case-control study

A retrospective case-control study was conducted to assess whether patients who underwent sequential preoperative disinfection before primary total knee or unicompartmental arthroplasty had a lower rate of postoperative infection than those who did not. In our study, 1025 patients who underwent total knee or unicompartmental arthroplasty at 2 medical centers between September 1, 2020, and August 31, 2021, were enrolled. Statistical analysis was performed for 976 cases, including 966 and 10 uninfected and infected cases, respectively. All patients were followed up for 1-year. Data analysis was performed by binary logistic regression and adjusted for 2 confounding factors: general anesthesia and rheumatoid arthritis. IBM SPSS for Windows (version 25.0; IBM Co., Armonk, NY) software was used to perform all statistical analyses. During the study period, of the 976 patients, 10 cases of infections were detected. Sequential pre-disinfection (adjusted odds ratio 0.14, 95% confidence interval: 0.03-0.54, P = .005) could reduce the incidence of infection. Based on the results of this study, bathing the whole lower limb with 2% chlorhexidine on the night before surgery followed by 70% alcohol application 1 hour before surgery is effective for preventing periprosthetic joint infection during primary total knee or unicompartmental arthroplasty.

Rank-Ordered List of Cost-effective Strategies for Preventing Prosthetic Joint Infection in Total Joint Arthroplasty in an Academic US Hospital

Although the overall rate of prosthetic joint infection (PJI) is low, it remains a major complication associated with total joint arthroplasty (TJA). PJI represents a significant economic burden to the health care system that is projected to increase commensurate with increasing joint replacement volumes. This review provides a rank-ordered list of cost-effective strategies that are performable intraoperatively and have data supporting their efficacy at preventing PJI after TJA. This study may be helpful in assisting surgeons, ambulatory surgery center owners, and hospital acquisition committees to make reasonable and cost-conscious decisions in the face of changing reimbursement. [Orthopedics. 2023;46(6):327-332.].

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.

Clinical outcomes of proximal femoral reconstruction technique combined with THA in the treatment of high dislocation secondary to septic arthritis: a retrospective single-center study

PURPOSE

The aim of this retrospective study was to examine the clinical outcomes and complications of proximal femur reconstruction (PFR) combined with total hip arthroplasty (THA) in patients with high hip dislocation secondary to septic arthritis (SA).

METHODS

Between September 2016 to September 2021, we performed a series of 15 consecutive PFR combined with THA on patients with high dislocation of the hip secondary to SA, of these,12 hips were reviewed retrospectively, with a mean follow-up of 2.5 years (range, 1.5-6 years). The mean age of the patients at the time of surgery was 52 years (range, 40-70 years).

RESULTS

All patients were followed up. At 1-year postoperative follow-up, the median HHS increased from 32.50 preoperatively to 79.50 postoperatively. The median VAS decreased from 7 before surgery to 2 at 1 year after surgery. The median LLD reduced from 45 mm preoperatively to 8 mm at 1 year after surgery. The mean operative time 125 ± 15 min (range 103-195 min). Mean estimated blood loss was500 ± 105ml (range 450-870 ml). Mean hospital days 9.5 days (range 6-15 days). Two patients developed nerve injuries that improved after nutritional nerve treatment. One patient had recurrent postoperative dislocation and underwent reoperation, with no recurrence dislocation during the follow-up. There were no cases of prosthesis loosening during the follow-up period. One patient developed acute postoperative periprosthetic joint infection (PJI) that was treated with Debridement, Antibiotics and Implant Retention (DAIR) plus anti-infective therapy, with no recurrence during 2 years of follow-up.

CONCLUSION

This study indicates PFR combined with THA shows promise as a technique to manage high hip dislocation secondary to SA, improving early outcomes related to pain, function, and limb length discrepancy.

Acute multifocal osteomyelitis with septic arthritis caused by nontyphoidal Salmonella in an immunocompetent young adult: a case report

Nontyphoidal Salmonella (NTS) infection can lead to gastroenteritis, enteric fever, and bacteremia. However, bone and joint infections due to NTS are rarely encountered, accounting for only 0.8% of all Salmonella infections and 0.45% of all types of osteomyelitis. We herein report an extremely rare case of acute multifocal osteomyelitis (bilateral femurs and left tibia) with septic arthritis of the bilateral hips caused by Salmonella Dublin in an immunocompetent adult. We performed thorough debridement of the bilateral hips and surgical decompression of the involved bones. At 1 year of follow-up, the patient's inflammatory biomarkers were within normal limits, and clinical and radiologic examinations showed no signs of infection. We emphasize that invasive NTS can lead to multifocal bone and joint infections in immunocompetent adults. The manifestations of Salmonella osteomyelitis may be insidious; thus, we recommend performing a simultaneous magnetic resonance imaging examination of the bone adjacent to the infected joint to avoid missed or delayed diagnosis. Thorough surgical debridement combined with a long course of sensitive antibiotic therapy is essential to eradicate the infection.

Clinical evaluation of total hip arthroplasty for osteoarthropathy secondary to septic hip arthritis

To investigate the clinical efficacy and prognosis of total hip arthroplasty (THA) in patients with osteoarthropathy secondary to septic hip arthritis. A total of 100 patients with osteoarthropathy secondary to septic hip arthritis who underwent surgery in our hospital from December 2010 to December 2021 were selected. Operative data were summarized. Moreover, preoperative and postoperative differences in Harris score, Western Ontario and McMaster Universities Osteoarthritis Index score, Visual Analogue Scale score, hip mobility were compared. Due to hospital transfer, the epidemic of COVID-2019 and other reasons, 10 patients were lost to follow-up and finally 90 patients were recorded. According to the results, the mean operation time (OT) was 1.78 ± 0.32 (hour), the mean intraoperative blood loss (BL) was 586.62 ± 31.66 (mL), the mean red blood cell (RBC) transfusion was 3.84 ± 0.75 (U), and 2 cases were positive, and 88 cases were negative for Trendelenburg sign. Postoperatively, the unequal length of the lower limbs and the Visual Analogue Scale score were significantly lower than that of the preoperative, while the Western Ontario and McMaster Universities Osteoarthritis Index score, Harris score, and hip joint range of motion were significantly higher than those of the preoperative (P < .05). At the last follow-up, all the incisions healed with no deep infections, 1 case suffered from transient sciatic nerve palsy, 2 cases had intermuscular venous thrombosis, and 2 cases who occurred hip dislocation recovered after treatment. THA surgery for osteoarthropathy secondary to septic hip arthritis has a good effect, relieving the patient's pain effectively, improving prognosis and joint mobility. For osteoarthropathy secondary to septic hip arthritis, THA may be meaningful in terms of prognosis.

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children-Review of a Retrospective Multicenter Database

BACKGROUND

There is limited information on the presentation and management of upper extremity septic arthritis (UESA) in children. Our purpose was to report on the characteristics and short-term treatment outcomes of pediatric UESA from a multicenter database.

METHODS

Patients with UESA were identified from a multicenter retrospective musculoskeletal infection database. Demographics, laboratory tests, culture results, number of surgeries, and complications were collected.

RESULTS

Of 684 patients with septic arthritis (SA), 68 (10%) patients had UESA. Septic arthritis was most common in the elbow (53%), followed by the shoulder (41%) and wrist (4%). The median age at admission was 1.7 years [interquartile range(IQR, 0.8-8.0 y)] and 66% of the cohort was male. Blood cultures were collected in 65 (96%) patients with 23 (34%) positive results. Joint aspirate and/or tissue cultures were obtained in 66 (97%) patients with 49 (72%) positive results. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism overall, but Streptococcus was the most common pathogen in the shoulder. Sixty-six (97%) patients underwent irrigation and debridement, with 5 (7%) patients requiring 2 surgeries and 1 patient (1%) requiring 3 surgeries. The median length of stay was 4.9 days (IQR, 4.0-6.3 d). Thirty-one (46%) children had adjacent musculoskeletal infections and/or persistent bacteremia. No patients experienced venous thromboembolism, and 4 patients with associated osteomyelitis experienced a musculoskeletal complication (3 avascular necrosis, 1 pathologic fracture). One child had re-admission and 3 children with associated osteomyelitis had a recurrence of UESA. Comparison between elbow and shoulder locations showed that children with septic arthritis of the shoulder were younger (4.6 vs. 1.0 y, P =0.001), and there was a difference in minimum platelet count (280 vs. 358 ×10 9 cells/L, P =0.02).

CONCLUSIONS

UESA comprises 10% of cases of septic arthritis in children. The elbow is the most common location. Shoulder septic arthritis affects younger children. MSSA is the most common causative organism in UESA, but Streptococcus is common in shoulder septic arthritis. Irrigation and debridement result in excellent short-term outcomes with a low complication rate. Re-admissions and repeat surgical interventions are rare.

LEVEL OF EVIDENCE

Level IV, prognostic.

Prevotella bivia Septic Arthritis in an Immunocompetent Adult: A Case Report and Review of Literature

Septic arthritis is a medical emergency that requires prompt diagnosis to prevent long-term intra-articular complications. Prevotella bivia is an anaerobic gram-negative rod which has been infrequently reported to cause septic arthritis. We present a 49-year-old female that presented with spontaneous left knee pain and swelling without history of insult to the knee. She was initially misdiagnosed with patellar tendinitis and gout but later underwent joint aspiration due to worsening symptoms, which demonstrated 60 800/µL nucleated cells with a polymorphonuclear burden consistent with septic arthritis. Arthroscopy with irrigation and drainage was subsequently performed, and the patient was started on empiric antibiotics while awaiting cultures. Cultures grew Prevotella bivia, and antibiotics were deescalated to ertapenem alone followed by oral metronidazole. Prevotella species as a source of septic arthritis is rare, and its occurrence in a patient without known insult to the knee is even more uncommon. It is essential that it is recognized to treat appropriately and prevent long-term loss of function in the joint.

For Patients With Acute PJI Treated With Debridement, Antibiotics, and Implant Retention, What Factors Are Associated With Systemic Sepsis and Recurrent or Persistent Infection in Septic Patients?

BACKGROUND

Periprosthetic joint infection (PJI) can lead to a severe systemic inflammatory response and may result in systemic sepsis. However, little is known about how often systemic sepsis may occur in patients with PJI, and whether sepsis is associated with a greater likelihood of persistent or recurrent PJI.

QUESTIONS/PURPOSES

(1) Among patients who present with acute or acute hematogenous PJI and who were treated with debridement, antibiotics, and implant retention (DAIR), what proportion have sepsis and what factors are associated with a presentation with sepsis? (2) For patients presenting with sepsis, what factors are associated with persistent or recurrent PJI?

METHODS

In all, 320 patients who underwent DAIR for the treatment of acute postoperative or acute hematogenous PJI between January 2000 and December 2019 were included in this study. Exclusion criteria were patients with other known sources of infection, such as pneumonia or urinary tract infections, which could contribute to systemic sepsis (6% [18 of 320]), patients with chronic PJI, and those with less than 6 months of follow-up (21% [66 of 320]). Our final cohort consisted of 236 patients presenting with an acute postoperative or acute hematogenous PJI who underwent an irrigation and debridement procedure. Sepsis was defined by the criteria for systemic inflammatory response syndrome (SIRS) or bacteria-positive blood culture results. Inclusion of patients with positive blood culture by organisms that caused their joint infection was important as all patients presented with fulminant acute infection of a prosthetic joint. Data, including vital signs, surgical variables, and treatment outcomes, were collected retrospectively through a chart review of an electronic medical record system. The statistical analysis comparing patients with sepsis versus patients without sepsis consisted of logistic regression to identify factors associated with sepsis. After confirming its ability to identify patients with a higher association with the development of sepsis through area under the curve models, a nomogram was generated to standardize our results from the regression, which was supported by the area under the curve model, to help readers better identify patients who are more likely to develop sepsis.

RESULTS

A total of 44% (103 of 236) of patients had infections that met the criteria for sepsis. After controlling for confounding variables, including congestive heart failure, anemia, serum C-reactive protein (CRP), and the male sex, it was revealed that serum CRP (odds ratio 1.07 [95% confidence interval 1.04 to 1.11]; p < 0.001) and male sex (OR 1.96 [95% CI 1.03 to 3.81]; p = 0.04) were associated with the development of systemic sepsis. For patients presenting with sepsis, persistent or recurrent PJI were associated with an increased CRP level (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.01) and number of prior surgical procedures on the joint (OR 2.30 [95% CI 1.21 to 4.89]; p = 0.02).

CONCLUSION

Overall, our findings support that patients with systematic sepsis may benefit from two-stage revision rather than DAIR to decrease the bioburden more effectively, especially in those with methicillin-resistant Staphylococcus aureus and polymicrobial infections. High serum CRP levels and a history of prior surgical procedures on the involved joint should trigger prompt, aggressive surgical treatment if the patient's overall clinical status can tolerate such an intervention.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Latex Allergy as an Independent Risk Factor for Prosthetic Joint Infection

In response to increasing rates of self-reported latex allergies, changes have been made to prevent anaphylaxis in the operating room, including the use of latex-free gloves. However, the impact of these changes on the risk of prosthetic joint infection (PJI) after arthroplasty is unclear. This study evaluated whether documented latex allergy is an independent risk factor for PJI and aseptic revision surgery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A retrospective matched cohort study was conducted with an administrative claims database. A total of 17,501 patients who underwent TKA and had documented latex allergy were matched 1:4 with 70,004 control subjects, and 8221 patients who underwent THA and had documented latex allergy were matched 1:4 with 32,884 control subjects. Multivariable logistic regression showed that patients who had TKA and had a latex allergy showed significantly higher risk of PJI at both 90 days (odds ratio [OR], 1.26) and 1 year (OR, 1.22) and significantly higher risk of aseptic revision TKA at 1 year (OR, 1.21) after surgery compared with control subjects. Patients who had THA and had a latex allergy had significantly higher risk of PJI at 1 year (OR, 1.19) compared with control subjects. Rates of aseptic revision THA were higher in the latex allergy cohort but statistically comparable (P>.05). Latex allergy was associated with significantly increased risk of PJI and aseptic revision after TKA and significantly increased risk of PJI after THA. More work is needed to determine whether these risks can be mitigated or if latex allergy is an inherent, nonmodifiable risk factor requiring modification to typical arthroplasty pathways. [Orthopedics. 2022;45(4):244-250.].

Knee Arthrodesis for Mycobacterium avium Complex Native-Knee Septic Arthritis in a Patient with Dermatomyositis: A Case Report

CASE

A 43-year-old woman with dermatomyositis presented with Mycobacterium avium complex (MAC) knee septic arthritis with superimposed polymicrobial infection. After poor infection control with antibiotic therapy, she underwent debridement and antibiotic cement spacer placement, followed by knee arthrodesis 6 months later. At 2-year follow-up, she had no pain and was ambulating without assistive devices.

CONCLUSION

As far as we know, this is the first reported case of MAC native-knee septic arthritis successfully treated with antibiotic cement spacer followed by knee arthrodesis. This case sheds insight on treatment strategies for a rare native-knee infection.

Incision site fat thickness and 90-day complications for direct anterior and posterior approach total hip arthroplasty

BACKGROUND

Defining the distribution of subcutaneous fat around the hip in relation to different approaches for total hip arthroplasty (THA) may lead to a better understanding of the relationship between obesity and complications. The purpose of this study was to: (1) describe the intraoperative thickness of subcutaneous fat at the incision site for direct anterior (DAA) and posterior approaches (PA) for THA; and (2) examine the relationship between fat thickness and 90-day postoperative complications.

METHODS

Intraoperative fat measurements were obtained at the anterior incision site (AT-IS) of the DAA (n = 60) and the lateral incision site (LT-IS) of the PA (n = 64). Lateral hip fat thickness was measured from preoperative anteroposterior pelvis radiographs (LT-XR). Body mass index (BMI), sex, age, and 90-day complications were collected retrospectively.

RESULTS

Patients within the same demographic groupings had significantly more fat laterally than anteriorly, between 9.6 mm and 17.96 mm. Return to the OR was significantly associated with BMI, AT-IS, and LT-IS. Wound complications were significantly associated with AT-IS. Periprosthetic joint infection (PJI) was significantly associated with BMI and LT-IS. No outcome variables were associated with LT-XR, approach, sex, or age. LT-XR was strongly correlated with AT-IS and LT-IS.

CONCLUSIONS

Regardless of BMI, sex, or age more soft tissue was encountered with a PA compared to a DAA. General adiposity was associated with return to the OR. Excess incisional fat was associated with wound complications following a DAA and PJI after a PA. LT-XR and clinical examination near the proposed incision, may provide helpful data in making preoperative risk assessments.

Glenohumeral joint effusion assessment with point-of-care ultrasound

ABSTRACT

Ultrasound has favorable diagnostic accuracy for detecting glenohumeral joint effusions. This article describes an easy-to-learn and interpret limited glenohumeral joint ultrasound examination that can help guide further evaluation and treatment. We report on a patient ultimately diagnosed with septic arthritis of the glenohumeral joint, the associated joint effusion having been detected on bedside ultrasound. This ultrasound examination is applicable to generalist PAs and those working in orthopedics and acute care settings.

The Use of Biomarkers in the Early Diagnosis of Septic Arthritis and Osteomyelitis-A Pilot Study

BACKGROUND

The diagnosis of septic arthritis (SA) and osteomyelitis (OM) has remained challenging in the pediatric population, often accompanied by delays and requiring invasive interventions. The purpose of this pilot study is to identify a novel panel of biomarkers and cytokines that can accurately differentiate SA and OM at initial presentation using serum alone.

METHODS

Twenty patients below 18 years old whose working diagnosis included SA (n=10) and OM (n=10) were identified. Serum was collected at initial evaluation. Each sample underwent seven ELISA [C1-C2, COMP, CS-846, hyaluronan, procalcitonin, PIIANP, C-terminal telopeptide of type II collagen (CTX-II)] and 65-plex cytokine panels. Principal component and Lasso regression analysis were performed to identify a limited set of predictive biomarkers.

RESULTS

Mean age was 4.7 and 9.5 years in SA and OM patients, respectively (P=0.029). 50% of SA patients presented within 24 hours of symptom onset, compared with 0% of OM patients (P=0.033). 30% of SA patients were discharged home with an incorrect diagnosis and re-presented to the emergency department days later. At time of presentation: temperature ≥38.5°C was present in 10% of SA and 40% of OM patients (P=0.12), mean erythrocyte sedimentation rate (mm/h) was 51.6 in SA and 44.9 in OM patients (P=0.63), mean C-reactive protein (mg/dL) was 55.8 in SA and 71.8 in OM patients (P=0.53), and mean white blood cells (K/mm3) was 12.5 in SA and 10.4 in OM patients (P=0.34). 90% of SA patients presented with ≤2 of the Kocher criteria. 100% of SA and 40% of OM patients underwent surgery. 70% of SA cultures were culture negative, 10% MSSA, 10% Kingella, and 10% Strep pyogenes. 40% of OM cultures were culture negative, 50% MSSA, and 10% MRSA. Four biomarkers [CTx-II, transforming growth factor alpha (TGF-α), monocyte chemoattractant protein 1 (MCP-1), B cell-attracting chemokine 1] were identified that were able to classify and differentiate 18 of the 20 SA and OM cases correctly, with 90% sensitivity and 80% specificity.

CONCLUSIONS

This pilot study identifies a panel of biomarkers that can differentiate between SA and OM at initial presentation using serum alone.

LEVEL OF EVIDENCE

Level II-diagnostic study.

What Is the Impact of Automated Synovial Cell Counting on Different Aseptic Causes and Periprosthetic Conditions Associated With Revision THA?

BACKGROUND

Studies have suggested that automated synovial cell counting may overestimate the white blood cell (WBC) count, resulting in false positive tests when evaluating patients for the possibility of periprosthetic joint infection (PJI) after THA. However, associations between WBC counts high enough to mimic PJI in patients whose arthroplasties are not infected but rather are experiencing a variety of aseptic problems-including but not limited to metallosis, polyethylene wear, and recurrent dislocation-have not, to our knowledge, been adequately addressed. In addition, there is a lack of analyses about the polymorphonuclear percentage (PMN%) when assessed by automated analyzers in this context.

QUESTIONS/PURPOSES

In the context of different indications for aseptic revision and different periprosthetic hip pathologic findings, we asked: (1) What were the synovial WBC count levels, and what proportion of values were above the 2018 International Consensus Meeting (ICM) cutoff (3000 cells/μL)? (2) What were the synovial PMN% levels, and what proportion of values were above the 2018 ICM (70%)?

METHODS

We retrospectively studied the preoperative cell count analyses of synovial fluid in patients who underwent revision THA for aseptic reasons at our tertiary referral arthroplasty center between January 2015 and December 2017. We considered all revisions performed on patients during that time potentially eligible, and after prespecified exclusions were applied (exclusions mainly included 15% [197 of 1306] sporadic missing data and 12% [155 of 1306] insufficient synovial fluid obtained in the aspirate), a total of 702 patients undergoing revision THA for aseptic reasons remained for the final analysis. As far as we know, no patients underwent re-revision for PJI at a mean follow-up of 46 ± 11 months, which tends to confirm our impression that indeed these hips did not have PJI. Cell count analyses were conducted using an automated analyzer. Clinical findings, preoperative radiographs, and surgical reports--confirmed by available histologic results--were used to establish diagnoses. We evaluated these hips considering the recommendations of the 2018 ICM (WBC count of 3000 cells/μL and PMN% of 70%) to see what proportion of them would have been characterized as likely having PJI on basis of those cutoff values. The mean WBC count for the entire cohort was 2120 ± 2395 cells/μL. The mean PMN% for the entire cohort was 36% ± 22%.

RESULTS

Compared with aseptic loosening and recurrent dislocation, polyethylene wear had the highest mean WBC count (3817 ± 3711 cells/μL; p < 0.001). Of the investigated periprosthetic conditions, wear-induced synovitis had the highest value (4464 ± 3620 cells/μL; p < 0.001). Considering the ICM threshold, polyethylene wear showed the highest proportion of WBC counts above 3000 cells/μL among the indications for aseptic revision (60% [25 of 42]; p < 0.001). Of the periprosthetic conditions, wear-induced synovitis showed the highest proportion beyond the ICM cutoff (60% [50 of 83]; p < 0.001). The mean PMN% for aseptic causes ranged between 28% and 44% without differences among them (p = 0.12). Patients with metallosis had the highest mean PMN% of the periprosthetic conditions investigated (45% ± 25%; p = 0.007). Regarding the ICM threshold, metallosis resulted in the largest proportion of patients with a PMN% above 70% (21% [10 of 47]; p = 0.003), and that for wear-induced synovitis was 6% (5 of 83; p = 0.42) and for osteolysis was 3% (1 of 33; p = 0.51). There were no differences among aseptic loosening, recurrent dislocation, and polyethylene wear in terms of the proportion above 70% among the aseptic revision causes.

CONCLUSION

Using automated cell counting, we found that WBC counts differ widely across indications for aseptic revision THA, and a high proportion of patients who underwent revision THA for aseptic reasons had WBC counts above the commonly used threshold of 3000 cells/μL. However, the PMN% was much less affected in several common indications for aseptic revision THA, making this measure more reliable for interpreting aspiration results using an automated analyzer. Based on the data distributions we observed, manual counting techniques might be considered in particular among patients with polyethylene wear, metal-on-metal bearing surfaces, or suspected metallosis. However, an elevated WBC count alone, observed using an automated analyzer in the context of polyethylene wear, should not be considered to be strongly suggestive of PJI, since that finding occurred so commonly among patients without infection.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Septic arthritis of the wrist and the hand: - An Emergency department case study

Joint pain is a common presentation in the Emergency department. There are countless potential causes for pain and swelling in a joint. Septic arthritis is a true joint emergency as it can lead to rapid, irreversible destruction of the joint. If not diagnosed early this infection can lead to considerable functional deficit. Our case is unique in that our patient presented to the Emergency department requesting referral to the fracture clinic for continued management of a suspected scaphoid bone fracture but was found to have Neisseria gonorrhoea causing septic arthritis of the joint. This case highlights the importance of accurate history taking, clinical examination and assessment of the patients presenting with joint pain.

Point-of-Care Ultrasound of a Shoulder Effusion in a Child With Septic Arthritis: A Case Report

ABSTRACT

Point-of-care musculoskeletal ultrasound can facilitate diagnosis of joint effusions and help guide management of suspected septic joints. This case report describes a previously healthy pediatric patient with acute onset shoulder pain and fever who was found to have leukocytosis and bacteremia. Point-of-care ultrasound (POCUS) demonstrated a unilateral shoulder joint effusion. After POCUS was performed, purulent fluid was aspirated from the joint, and she was diagnosed with a septic shoulder. We review the ultrasound technique, sonographic findings, and literature regarding POCUS for shoulder effusions.

[Routine preoperative examination for diagnosis of periprosthetic joint infection and its recurrence in revision hip arthroplasty]

OBJECTIVE

To evaluate diagnostic value of routine preoperative laboratory tests such as erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and microbiological examination of joint aspirate in patients with periprosthetic joint infection or its recurrence in patients scheduled for revision hip arthroplasty.

MATERIAL AND METHODS

There were 117 patients. Preoperative CRP and ESR, the culture of pre- and intraoperative joint aspirates and tissue biopsies were studied. We analyzed diagnostic significance of these parameters and the likelihood of periprosthetic joint infection depending on increase of CRP/ESR and previous joint infection.

RESULTS

According to microbiological data, periprosthetic joint infection was diagnosed in 19.7% of patients. High CRP in this group significantly increased the chance of joint infection diagnosis (OR 6.3; 95% CI 1.491-26.615). Concomitant increase of both ESR and CRP increased this likelihood by 7.7 times (OR 7.778; 95% CI 0.931-66.296). In the 2^nd group, periprosthetic joint infection was confirmed in 25% of patients. At the same time, detection of pathogen in isolated or combined increase in CRP and ESR was less likely compared to the control group. Prognostic value of negative preoperative microbiological examination of joint aspirate was only 93%. We failed to obtain aspirate in 21.4% of cases.

CONCLUSION

Increase of the routine serological parameters before revision hip arthroplasty is more sensitive for prediction of periprosthetic joint infection in patients without previous infection. Previous joint infection reduces diagnostic value of ESR and CRP in detection of recurrent periprosthetic joint infection. Preoperative examination of joint aspirate is not sufficient for etiological diagnosis of periprosthetic joint infection. However, positive microbiological culture should be taken into account for the choice of further management.

Septic Arthritis: Diagnosis and Treatment

Septic arthritis must be considered and promptly diagnosed in any patient presenting with acute atraumatic joint pain, swelling, and fever. Risk factors for septic arthritis include age older than 80 years, diabetes mellitus, rheumatoid arthritis, recent joint surgery, hip or knee prosthesis, skin infection, and immunosuppressive medication use. A delay in diagnosis and treatment can result in permanent morbidity and mortality. Physical examination findings and serum markers, including erythrocyte sedimentation rate and C-reactive protein, are helpful in the diagnosis but are nonspecific. Synovial fluid studies are required to confirm the diagnosis. History and Gram stain aid in determining initial antibiotic selection. Staphylococcus aureus is the most common pathogen isolated in septic arthritis; however, other bacteria, viruses, fungi, and mycobacterium can cause the disease. After synovial fluid has been obtained, empiric antibiotic therapy should be initiated if there is clinical concern for septic arthritis. Oral antibiotics can be given in most cases because they are not inferior to intravenous therapy. Total duration of therapy ranges from two to six weeks; however, certain infections require longer courses. Consideration for microorganisms such as Neisseria gonorrhoeae, Borrelia burgdorferi, and fungal infections should be based on history findings and laboratory results.

Native Hip Septic Arthritis in the Setting of Postpartum Gynecologic Infection: A Case Report

CASE

A 34-year-old healthy G3P3 woman, 1.5 weeks postpartum, presented with hip pain, fever, and a rash. Clinical examination, laboratory testing, and microbiologic cultures identified bacterial arthritis of the right hip; obstetric/gynecologic examination and cultures identified endometrial, vaginal, and urinary tract infections caused by the same pathogen, group A streptococcus, likely contracted from her 5-year-old son who had streptococcal pharyngitis. She underwent successful surgical decompression of the hip with concurrent medical management of toxic shock syndrome (TSS).

CONCLUSIONS

Hematogenously spread septic arthritis may occur in the absence of positive blood cultures during the postpartum period, increasing the risk of developing TSS.

[Coexistent septic arthritis and spondylodiscitis as important differential diagnosis in immunosuppressed patients]

Die septische Arthritis und Spondylodiszitis stellen bei immunsupprimierten Patienten eine wichtige Differenzialdiagnose des Gelenk- oder Wirbelsäulenschmerzes dar. Hierbei kommt es zu einem Erregerbefall eines Gelenks bzw. einer Bandscheibe und angrenzender Wirbelkörper. Es zeigen sich meist unspezifische Symptome wie lokaler Gelenk- oder Rückenschmerz, Fieber und verringerter Allgemeinzustand. Diagnostisch kann bei klinischem Verdacht die bakterielle Besiedelung durch eine Gelenkpunktion und Blutkulturen nachgewiesen werden. Zur Diagnosefindung einer Spondylodiszitis sollte eine bildmorphologische Darstellung mittels Magnetresonanztomographie erfolgen. Neben einer adäquaten Schmerztherapie und empirischer antibiotischer Therapie sollte bei einer septischen Arthritis die chirurgische Entfernung des infektiösen Materials aus dem Gelenk angestrebt werden. Eine chirurgische Versorgung der Spondylodiszitis sollte bei auftretenden Komplikationen erfolgen. Die folgende Kasuistik stellt den gleichzeitigen Befund einer septischen Polyarthritis und Spondylodiszitis bei einem immunsupprimierten Patienten mit HIV-Infektion vor und zeigt eindrücklich das Auftreten von Komplikationen bei Verzögerung einer adäquaten Therapie.

Treatment of Psoas abscess related coxarthrosıs due to salmonella infection in a patient wıth chronic renal failure. A case report

INTRODUCTION

The most common microorganisms isolated from septic arthritis are staphylococcus aureus and streptoccocci. Septic arthritis due to Salmonella spp. is extremely rare.

PRESENTATION OF CASE

A 55-year-old man, chronic renal failure, is admitted hip arthtritis with newly arised symptoms. The findings were not compatible with primary arthritis. The laboratory findings which include white blood cell count, erythrocyte sedimentation rate (esr) and c-reactive protein (crp) were elevated. In magnetic resonance (mr) imaging there were psoas abscess and septic arthritis of the hip. They were treated by drainage. The culture was confirmed as Salmonella spp. Antibiotic treatment were done.

DISCUSSION

Uremia in patients with chronic renal failure is associated with a state of immune dysfunction. In our case, uremia may cause immunosuppressive conditions and hematogenous dissemination of salmonella.

CONCLUSION

Salmonella infection in a patient with chronic renal failure may be occured. It must be kept in mind that early diagnosis, administration of appropriate systemic antibiotics and surgical intervention play a pivotal role in successful management.

KEY WORDS

Arthritis, Failure, Psoas, Salmonella Renal Abscess.

Clinical features and outcomes in children with bone and joint infections of the ankle or foot

BACKGROUND

The foot and ankle are uncommon sites of bone and joint infections (BJIs) in children. The objectives of the present study were to determine the clinical and bacteriologic features of BJIs and to assess any associated complications and orthopedic sequelae.

METHODS

We performed a retrospective, single-center study of children treated for foot or ankle BJIs between 2008 and 2018 in a French university medical center. A total of 23 children were included. The median age at diagnosis was 9.1 years. Osteomyelitis was noted in 14 cases; it involved the calcaneus in seven cases, the distal fibula in four cases, the first metatarsal in two cases, and the distal tibia in one case. Arthritis affected the ankle in six cases and the cuneiform-cuboidal joint in one case. In two cases, osteoarthritis of the ankle was associated with distal osteomyelitis of the tibia. Clinical, radiological, and bacteriological parameters, surgical procedures, complications, and sequelae were recorded and analyzed.

RESULTS

The median (range) time to diagnosis was 3.18 days (0-10), and trauma was reported in four cases. Fever was present on admission in 18 cases, and the serum C-reactive protein level was elevated in 22 cases. Standard X-rays showed osteolysis in one case and bone sequestration in another. Staphylococcusaureus was identified in 10 cases. Surgery was performed in 17 cases. A subperiosteal abscess that required surgical drainage complicated 10 cases of osteomyelitis. No recurrence was observed. At the last follow-up, the median (range) age was 11.9 years (1.5-19). Sequelae (spontaneous tibia-talus fusion, first metatarsal epiphysis fusion, and varus deformity of the hindfoot) were observed in three cases, all of which were initially complicated by an abscess.

CONCLUSION

Physicians should be aware that pediatric BJIs of the lower limb may involve the foot and ankle. S. aureus is frequently involved. In cases of osteomyelitis, complications are closely associated with subperiosteal abscesses justifying an early diagnosis. These BJIs must be treated rapidly, and the risk of sequelae justifies long-term follow-up.

Coronavirus Disease 19 (COVID-19) complicated with post-viral arthritis

Coronavirus disease 2019 (COVID-19) was reported in Europe in the beginning of February 2020. Typical symptoms included fever, cough and dyspnea, and not much was known about the clinical evolution of the disease. Herein, we report a case of a late complication of COVID-19 infection in a 41-year-old female. The patient presented with a 4-day history of myalgia, low fever, rhinorrhea and loss of smell. COVID-19 was confirmed by real-time polymerase chain reaction (PCR). The patient recovered with conservative treatment, and PCR for COVID-19 turned negative after 5 weeks. However, at 4 weeks after the beginning of the viral symptoms, the patient developed severe arthralgia of some interphalangeal joints of the hands, that lasted for 4 weeks. Laboratory workup revealed no significant changes, and the symptoms resolved with a short course of oral steroids. Reactive viral arthritis might be a late complication of COVID-19.

Surgical Treatment of Acute Periprosthetic Knee Infection with Concurrent Presumed COVID-19: A Case Report

CASE

We report the case of a 64-year-old man who presented with a late onset of acute periprosthetic joint infection after total knee arthroplasty and a positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test. We describe our perioperative protocol and challenges for ensuring the safety of healthcare providers while operating on a coronavirus disease 2019 (COVID-19)-positive patient.

CONCLUSIONS

Given the incredible spread of COVID-19 globally, hospitals should anticipate perioperative protocols for the surgical management of COVID-19-positive patients with concurrent pathology to ensure safety to healthcare providers.

Characteristics of Pyogenic Musculoskeletal Infections in Older Children and Adolescents

The characteristics and clinical consequences of pyogenic bone and joint infections in older children and adolescents have received little attention. This study evaluated the presentation and complications of musculoskeletal infections involving the pelvis and extremities in children older than 10 years. Thirty patients 10 to 17 years old (mean, 12.7 years old) were treated for musculoskeletal infections. Mean time to diagnosis was 9.2 days. Prior to correct diagnosis, 83% were assessed by at least 1 outpatient provider. At the time of admission, 55% were weight bearing and 93% were afebrile. Twenty-eight percent had a multifocal infection. More than one-third had serious medical complications or orthopedic sequelae; compared with patients without complications, this group had a significantly higher admission C-reactive protein and longer hospital stay. Symptoms of musculoskeletal infection common among young children may be absent in adolescents. Axial imaging is recommended to identify adjacent or multifocal disease. The Kocher criteria are less sensitive for septic hip arthritis in the adolescent population. Prompt recognition and treatment are critical to avoid medical and musculoskeletal complications. [Orthopedics. 2020;43(4):e291-e298.].

Two-stage total hip arthroplasty for septic arthritis through the minimally invasive direct anterior approach

The use of minimally invasive direct anterior approach to perform total hip arthroplasty is gaining increasing popularity for its short-term advantages, compared to other approaches. Nevertheless, its use in hip revision surgery has been criticized. We report here the first case of hip septic arthritis treated with two-stage THA through this tissue-sparing approach, with good implant positioning and functional results.

Streptococcus dysgalactiae septic arthritis of sternoclavicular joint with bacteraemia

Invasive infections due to Streptococcus dysgalactiae are uncommon in the adult population, and sternoclavicular joint septic arthritis (SCSA) is usually caused by other organisms such as Staphylococcus aureus and Pseudomonas aeruginosa. We hereby report a case of SCSA caused by this organism. The patient responded well to intravenous antibiotics and recovered fully without any surgical intervention.

Burkholderia pseudomallei septic arthritis in Type-2 diabetes mellitus patients: Report of two cases

Two cases of Burkholderia pseudomallei septic arthritis are presented with a brief review of the literature. B. pseudomallei septic arthritis most commonly occurs in diabetics and other immunocompromised patients and may prove fatal despite appropriate therapy. Clinical and microbiological suspicion of B. pseudomallei infection may help in providing appropriate empirical therapy.

Pyogenic Arthritis

The incidence of septic arthritis among children in developed countries is estimated to be 4 to 10 cases per 100,000 children per year, peaking at about age 3 years. The most common causative organism is Staphylococcus aureus, although the microbiology varies by age. Prompt diagnosis and treatment is critical to prevent long-term sequelae. Empiric therapy should target the most likely causative organism(s) and total duration generally falls between 10 days and 4 weeks depending on clinical course, patient age, and organism. A short intravenous course is sufficient in most cases. Unusual and alternate causes of arthritis should be considered in special cases. [Pediatr Ann. 2019;48(9):e354-e359.].

High 2-year mortality and recurrent infection rates after surgical treatment for primary septic arthritis of the hip in adult patients: An observational study

Primary septic arthritis of the hip is rare and potentially devastating in adults. Its optimal surgical treatment and clinical outcomes remain unclear.In this retrospective cohort study, we investigated mortality and reinfection rates after surgery of patients with septic hip arthritis. We reviewed patients treated for primary septic hip joints from October 2005 to December 2016. A total of 51 adult patients were identified, and 38 among them had destructive hip joints. A poor postoperative outcome was defined as mortality or recurrent infection within 2 years of surgery.After surgery, 7 (13.7%) patients died within 1 year and 5 (9.8%) patients developed a recurrent hip infection within 2 years. Therefore, poor outcomes occurred in 22% (n = 11) of the study cohort. Among the 38 patients with a destructive hip joint, 7 (18.4%) died within 1 year after surgery and 4 (10.5%) developed a recurrent hip infection within 2 years of surgery. Correlative infections other than infected hip joint and liver cirrhosis were identified as risk factors for poor outcomes.In conclusion, clinical physicians treating adult primary septic hip joints should be cognizant of the high failure rate of surgical treatment. In addition, the high mortality rate should be considered during the discussion of surgical treatment with these patients and their families.

Modified abaxial approach for resection of the distal sesamoid bone and distal interphalangeal joint while preserving the digital flexor tendons of three Angus bulls with septic arthritis

CASE DESCRIPTION 3 Angus bulls, aged 2 to 3 years, with severe lameness of 2 to 4 weeks' duration and swelling proximal to the coronary band of the affected limb were evaluated after failing to respond to antimicrobial treatment. CLINICAL FINDINGS Septic arthritis of a distal interphalangeal joint (DIPJ) was diagnosed in all 3 bulls on the basis of results of a physical examination, radiographic and ultrasonographic evaluations of the affected foot, and cytologic evaluation of synovial fluid from the affected DIPJ. TREATMENT AND OUTCOME A novel modified abaxial approach was used to resect the infected distal sesamoid bone (navicular bone) and DIPJ of all 3 bulls. A window was created in the abaxial hoof wall that was lateral to and of sufficient size to extract the navicular bone. Following removal of the navicular bone, the DIPJ was debrided and resected and an orthopedic block was applied to the contralateral claw to minimize weight bearing on the infected digit. Two bulls also had a fiberglass cast applied to the affected limb to help immobilize the DIPJ. All 3 bulls recovered without complications, and 2 bulls were no longer lame, whereas the remaining bull was only mildly lame, at 4 to 5 weeks after surgery. CLINICAL RELEVANCE The modified abaxial approach described for surgical resection of the DIPJ allowed extraction of the infected navicular bone without damage to the digital flexor tendons, something that cannot be achieved with other abaxial approaches. This approach is best used for patients without septic tenosynovitis.

[Arthrodesis of Interphalangeal Joints of the Hand by an External Fixator in Managing Conditions Resulting from Septic Arthritis]

PURPOSE OF THE STUDY Arthrodesis of interphalangeal joints of the hand is a method used to treat conditions associated with joint destruction, instability and pain. Our study aims to evaluate the outcomes of the treatment of sequelae of septic arthritis of interphalangeal joints by arthrodesis with external fixation. This topic is hardly covered in literature. Moreover, it compares the outcomes of application of this method in diabetic patients and non-diabetic population. MATERIAL AND METHODS Arthrodesis by means of Stellbrink external fixator was performed in 17 patients who had suffered septic arthritis of interphalangeal joints of the hand. The following parameters were followed in patients in our group: age, sex, etiology of disease, smoking, diabetes, affected fingers and joints of the hand, side, microbial culture finding, wound healing, postoperative ATB therapy and its duration, radiographic signs of the union of arthrodesis and potential complications. RESULTS The group included 8 men and 9 women. The mean age was 66.2 years. 5 patients in the group were diabetic. In 16 patients the wound healed per primam, in 1 case per secundam. The average duration of postoperative ATB therapy was 4.3 weeks. The X-ray showed the union of fused articular surfaces at 6.9 weeks on average. Complications occurred in 3 patients, namely 1 case of secondary wound healing, 1 case of nail bed damage and 1 case of flexor tenosynovitis of the operated finger. The arthrodesis was successfully healed in all the patients and a no difference was detected between diabetic and nondiabetic patients. DISCUSSION When arthrodesis of interphalangeal joints of the hand is performed using an external fixator, the metal material is introduced outside the area of inflammation, or the field potentially at risk of infection, therefore this method is predetermined for surgeries in the terrain changed by inflammation or potentially at risk of inflammation. Compared to the other methods such as arthrodesis by inserting K-wires intramedullary, there is no risk of migration of the metal material and the associated soft tissue irritation. CONCLUSIONS Our study confirms the safety and efficiency of arthrodesis of interphalangeal joints of the hand by means of an external fixator in treating the sequelae of septic arthritis. The union of arthrodesis with no complications was observed even in all the diabetic patients. Ranking among the main advantages of this method are the easy care for the surgical wound, achievement of easy and firm fixation with the possibility to apply an external fixator outside the area of the original infection. Key words:arthrodesis, external fixator, septic arthritis, interphalangeal joint.