Aim. Culture-based conventional methods are still the gold standard to identify microorganisms in hip and knee PJIs diagnosis. However, such approach presents some limitations due to prior antimicrobial treatment or the presence of unusual and fastidious organisms. Molecular techniques, in particular specific real-time and broad-range polymerase chain reaction (PCR), are available for diagnostic use in a suspected PJI. However, limited data is available on their sensitivity and specificity. This study aimed to evaluate the performance of a rapid and simple Investigational Use Only (IUO) version of the BioFire® JI multiplex PCR panel when compared to traditional microbiological procedures. Method. Fifty-eight native synovial fluid samples were recovered from 49 patients (female n=26; male =23) who underwent one or multiple septic or aseptic revision arthroplasties of the hip (n=12) and knee (n=46). The JI panel methodology was used either on specimens freshly collected (n=6) or stored at −80°C in our Musculoskeletal Biobank (n=52). The JI panel performance was evaluated by comparison with culture reference methods. Patient's medical records were retrieved from our institutional arthroplasty registry as well as our prospectively maintained PJI infection database. Results. The JI panel identified additional microorganisms in 3/39 (7.7%) positive cases, and a different microorganism in 1/39 (2.6%) sample. Out of 9/58 (15.5%) culture negative samples, two (22%) were positively detected by the JI panel. In total 49/58 (84%) native synovial fluid specimens were positive by culture methods, versus 39/58 (81.2%) with the JI panel. Ten samples are currently under investigation for confirmatory results. Out of 39 positive detections with the JI panel, 35 (89.7%) were concordant with the identified microorganism (n=29 same species; n=6 same genus). The combined information from the JI panel results and clinical records revealed the existence of 6/58 (10.3%) PJIs’ cases which would have required a different antibiotic therapeutic approach. Conclusions. The work presented, provides additional value for the clinical use of the JI panel to the improvement of PJI management in terms of rapid and successful treatment decisions, patient outcome, and healthcare costs. This technique shows high sensitivity to detect PJIs specific microorganisms in both fresh as well frozen native synovial fluid samples, thus emphasizing its use for retrospective studies analysis

Aims. The aim of this meta-analysis is to assess the association between exchange of modular parts in debridement, antibiotics, and implant retention (DAIR) procedure and outcomes for hip and knee periprosthetic joint infection (PJI). Methods. We conducted a systematic search on PubMed, Embase, Web of Science, and Cochrane library from inception until May 2021. Random effects meta-analyses and meta-regression was used to estimate, on a study level, the success rate of DAIR related to component exchange. Risk of bias was appraised using the (AQUILA) checklist. Results. We included 65 studies comprising 6,630 patients. The pooled overall success after DAIR for PJI was 67% (95% confidence interval (CI) 63% to 70%). This was 70% (95% CI 65% to 75%) for DAIR for hip PJI and 63% (95% CI 58% to 69%) for knee PJI. In studies before 2004 (n = 27), our meta-regression analysis showed a 3.5% increase in success rates for each 10% increase in component exchange in DAIR for hip PJI and a 3.1% increase for each 10% increase in component exchange for knee PJI. When restricted to studies after 2004 (n = 37), this association changed: for DAIR for hip PJI a decrease in successful outcome by 0.5% for each 10% increase in component exchange and for DAIR for knee PJI this was a 0.01% increase in successful outcome for each 10% increase in component exchange. Conclusion. This systematic review and meta-regression found no benefit of modular component exchange on reduction of PJI failure. This limited effect should be weighed against the risks for the patient and cost on a case-by-case basis. The association between exchange of modular components and outcome changed before and after 2004. This suggests the effect seen after 2004 may reflect a more rigorous, evidence-based, approach to the infected implant compared to the years before. Level of Evidence: Level III. Cite this article: Bone Jt Open 2021;2(10):806–812

Aims. The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD). Methods. In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L. Results. A total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity). Conclusion. OHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data. Cite this article: Bone Jt Open 2023;4(3):138–145

Aims. This study aimed to evaluate the BioFire Joint Infection (JI) Panel in cases of hip and knee periprosthetic joint infection (PJI) where conventional microbiology is unclear, and to assess its role as a complementary intraoperative diagnostic tool. Methods. Five groups representing common microbiological scenarios in hip and knee revision arthroplasty were selected from our arthroplasty registry, prospectively maintained PJI databases, and biobank: 1) unexpected-negative cultures (UNCs), 2) unexpected-positive cultures (UPCs), 3) single-positive intraoperative cultures (SPCs), and 4) clearly septic and 5) aseptic cases. In total, 268 archived synovial fluid samples from 195 patients who underwent acute/chronic revision total hip or knee arthroplasty were included. Cases were classified according to the International Consensus Meeting 2018 criteria. JI panel evaluation of synovial fluid was performed, and the results were compared with cultures. Results. The JI panel detected microorganisms in 7/48 (14.5%) and 15/67 (22.4%) cases related to UNCs and SPCs, respectively, but not in cases of UPCs. The correlation between JI panel detection and infection classification criteria for early/late acute and chronic PJI was 46.6%, 73%, and 40%, respectively. Overall, the JI panel identified 12.6% additional microorganisms and three new species. The JI panel pathogen identification showed a sensitivity and specificity of 41.4% (95% confidence interval (CI) 33.7 to 49.5) and 91.1% (95% CI 84.7 to 94.9), respectively. In total, 19/195 (9.7%) could have been managed differently and more accurately upon JI panel evaluation. Conclusion. Despite its microbial limitation, JI panel demonstrated clinical usefulness by complementing the traditional methods based on multiple cultures, particularly in PJI with unclear microbiological results. Cite this article: Bone Joint Res 2024;13(7):353–361

Aim. Dalbavancin is a novel second-generation lipoglycopeptide antibiotic with strong activity against many gram-positive bacteria and a prolonged half-life of 6–11 days. This allows a once-a-week intravenous application and therefore an outpatient intravenous therapy. Currently, only little is known about the use of Dalbavancin in Periprosthetic joint infection (PJI). The aim of this retrospective study, was to compare the outcome of hip and knee periprosthetic joint infections (PJI) in patients who received dalbavancin (DAL) with patients which was treated by standard of care antimicrobial agents (SoC). Methods. Between 02/2017 and 02/2020 a total of 89 (42 male/47 female) patients with PJI of the hip 56/89 (62.9%) and knee 33/89 (37.1%) who received at least one dosage of Dalbavancin were included. A 1:1 propensity-score (PS) matching between the DAL-group (n=89) and the SoC-group (n=89) was performed, using defined demographic covariates such as body-mass-index, age, sex, causative pathogens, knee or hip joint and infection after primary or revision surgery, surgical site infections, Charlson-comorbidity index and the types of infection (acute, late acute and chronic). Patient's demographics were analysed by our prospectively maintained institutional arthroplasty registry and PJI database. We analysed the outcome of the included patients evaluate the re-infection and re-revision rate and gave details about surgical management and the type of PJI with a minimum follow-up of one year. Results. Microbiological and clinical successes were achieved in 69 (77.5%) patients of the DAL-group and in 66 (74.2%) patients of the SoC-group. In the DAL-group 13 (14.6%) and in the SoC-group 12 (13.5%) patients had an infection related re-revision. Median follow-up was 706 (369; 1310) days in the DAL-group and 1329 (9; 3,549) days in the SoC-group. Overall, polymicrobial infections were found in 20 procedures (DAL-group: 10; SoC-group: 10) and monomicrobial infections in 154 (DAL-group: 75; SoC-group: 79). Polymicrobial infections were found in 20 patients and monomicrobial infections in 154. The most common microorganisms were Staphylococcus epidermidis n=63 (32.3%), Staphylococcus aureus n=27 (13.8%) and Cutibacterium spp. n=22 (11.3%). There are significantly less Gram-positive microorganisms (p=0.034) after re-revisions in patients with DAL treatment. Conclusions. Dalbavancin has excellent safety and high clinical effectiveness for Gram-positive PJIs

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Aims. Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT). Methods. Data was retrospectively analyzed from a single centre. In all, 29 consecutive joints prior to the implementation of an infection MDT in November 2016 were compared with 29 consecutive joints subsequent to the MDT conception. All individuals who underwent a debridement antibiotics and implant retention (DAIR) procedure, a one-stage revision, or a two-stage revision for an acute or chronic PJI in this time period were included. The definition of successfully treated PJI was based on the Delphi international multidisciplinary consensus. Results. There were no statistically significant differences in patient demographics or comorbidities between the groups. There was also no significant difference in length of overall hospital stay (p = 0.530). The time taken for formal microbiology advice was significantly shorter in the post MDT group (p = 0.0001). There was a significant difference in failure rates between the two groups (p = 0.001), with 12 individuals (41.38%) pre-MDT requiring further revision surgery compared with one individual (6.67%) post-MDT inception. Conclusion. Our standardized multidisciplinary approach for periprosthetic knee and hip joint infection shows a significant reduction in failure rates following revision surgery. Following implementation of our MDT, our success rate in treating PJI is 96.55%, higher than what current literature suggests. We advocate the role of a specialist infection MDT in the management of patients with a PJI to allow an individualized patient-centred approach and care plan, thereby reducing postoperative complications and failure rates. Cite this article: Bone Jt Open 2021;2(7):509–514

Periprosthetic joint infections (PJI) are challenging complications following arthroplasty. Staphylococci are a frequent cause of PJI and known biofilm producers. Reoperations for PJI of the hip or knee between 2012 and 2015 performed at Sahlgrenska University Hospital were identified. Medical records were reviewed, and clinical parameters recorded for patients whose intraoperative bacterial isolates had been stored at the clinical laboratory. Staphylococcal strains isolated from reoperations due to first-time PJI were characterised by their ability to form biofilms using the microtiter plate test. The study group included 49 patients (70 bacterial strains) from first-time PJI, whereof 24 (49%) patients had recurrent infection. Strong biofilm production was significantly associated with recurrent infection. Patients infected with strong biofilm producers had a five-fold increased risk for recurrent infection. Strong biofilm production was significantly associated with increased antimicrobial resistance and PJI recurrence. This underscores the importance of determining biofilm production and susceptibility as part of routine diagnostics in PJI. Strong staphylococcal biofilm production may have implications on therapeutic choices and suggest more extensive surgery. Furthermore, despite the increased biofilm resistance to rifampicin, results from this study support its use in staphylococcal PJI

Literature debates whether fluid aspirates for suspected PJI should undergo prolonged incubation for cultures. We looked at sensitivity and specificity of 14-day cultures, compared to 7-days, for aspirates from prosthetic hips and knees. Design and methods. Conducted at a quaternary referral centre for PJIs from Jan 2017 to July 2019. Suspected PJIs who underwent aspiration, incubated 14 days and later surgical intervention with minimum three tissue samples were included. Results. 176 aspirates were included. This is an increased number compared to our historic figures (average 88 Vs 48 pts/yr). 47 patients had fluid and tissue positive (true positive), 20 fluid +ive but tissue -ive (false positive), 98 fluid and tissue -ive (true negative) and 15 fluid negative but tissue +ive (False negative). Thus, sensitivity 76%, specificity 83%, positive predictive value70% and negative predictive value 87%. Of 88 positive aspirates, only 75% were within 7-day cultures. Low virulence organisms as Propionibacterium acnes and coagulase negative staph were grown later. Of 48 with only one tissue sample positive, 38 were culture-negative on aspiration and 6 grew different organisms on aspirate and tissues. Also, as many were cultured later, it suggests contamination. Conclusion. Increased numbers reflect quaternary referral nature of institution and increasing PJI load. Modest drop in sensitivity and specificity of 14-day cultures compared to 7-day(84 and 85% respectively) is due to higher false negatives. Contamination contributes to false-ive as more tissue samples become positive (there were 1076 tissue samples due to multiple sampling Vs 176 aspirates). Higher tissue yield may also be because they are more representative. Effect of antibiotic use between samples cannot be determined. Organism profile suggest14-day culture produces more contaminant growth despite a well-equipped microbiology lab with laminar airflow for subcultures. Caution in interpreting 14-day results in diagnosis of PJI of Hip and Knee is advised

Aim. It is unclear if the prevalence of resistance organisms causing (PJI) in total hip/knee arthroplasty is different among North/South American and European countries. Therefore, we sought to compare causative organisms, rates of resistant organisms, and polymicrobial infections in hospitals in North/South America, and Europe. Method. We performed a retrospective study of 654 periprosthetic hip (n=361) and knee (n=293) infections (January 2006-October 2019) identified at two facilities in the United States (US) (n=159), and single institutions located in Argentina (n=99), Uruguay (n=130), United Kingdom (UK) (n=103), Germany (n=59), and Russia (n=104). The analyses were performed for the entire cohort, knees, and hips. Alpha was set at 0.05. Results. Overall, the most frequent organisms identified were Staphylococcus aureus (24.8%) and Staphylococcus epidermidis (21.7%). The incidence of organisms resistant to at least one antibiotic was 58%. In this regard, there was a significant difference between hips (62.3%) and knees (52.6%) (p=0.014). The rates of resistant organisms among countries were significantly different: 37.7% (US), 66.7% (Argentina), 71.5% (Uruguay), 40.8% (UK), 62.7% (Germany), and 77.9% (Russia) (p<0.001). The overall incidence of polymicrobial infections was 9.3% and the rates across nations were: 9.4% in the US, 11.1% (Argentina), 4.6% (Uruguay), 4.9% (UK), 11.9% (Germany), and 16.3% (Russia) (p=0.026). In an exclusive analysis of the hips, the incidence of resistant organisms was 62.3% while polymicrobial infections accounted for 10.5% of all cultures. The rates of resistant organisms in each country were: 42.9% in the US, 59.2% (Argentina), 78.5% (Uruguay), 41.3% (UK), 63.9% (Germany), and 80.0% in Russia (p<0.001). The incidences of polymicrobial infections were: 9.1% in the US, 6.1% (Argentina), 6.5% (Uruguay), 6.5% (UK), 16.7% (Germany), and 21.7% in Russia (p=0.024). Regarding the knees, the incidence of resistant organisms was 52.6% while the frequency of polymicrobial infections was 7.8%. The rates of resistant organisms in each country were: 32.9% in the US, 74% (Argentina), 54.1% (Uruguay), 40.4% (UK), 60.9% (Germany), and 75% in Russia (p<0.001). The frequencies of polymicrobial infections were: 9.8% in the US, 16% (Argentina), 0% (Uruguay), 3.5% (UK), 4.3% (Germany), and 9.1% in Russia (p=0.072). Conclusions. Staphylococcus aureus and epidermidis accounted for almost 50% of all infections. The US and the UK had the lowest incidence of resistant organisms while Germany and Russia had the highest. The UK and Uruguay had the lowest rates of polymicrobial infections. These differences between countries and continents may affect comparative studies that evaluate treatments for PJI

In Canada, hip and knee replacements are each among the top three surgeries performed annually. In 2020, surgeries across the country were cancelled in response to the COVID-19 pandemic. We examined the impact on these joint replacement surgeries throughout the year.

Using the Discharge Abstract Database and National Ambulatory Care Reporting System, we developed a dataset of all 208,041 hip and knee replacements performed in Canada (except from Quebec) between January 1, 2019 to December 31, 2020. We compared patient and surgical characteristics (including sex, age, main diagnosis, and type of surgery (planned/urgent, primary/revision, inpatient/day surgery) in 2020 to 2019.

In 2020, hip and knee replacements volumes decreased by 18.8% compared to 2019. In April and May 2020, hip and knee replacements fell by 69.4% and 93.8%, respectively, compared to the same period in 2019. During those months, 66.5% of hip replacements were performed to treat hip fracture versus 20.2% in April and May 2019, and 64.5% of knee replacements were primaries versus 93.0% in April and May 2019. Patterns by patient age group and sex were similar compared to 2019. These patterns were similar across all provinces. By the summer, planned surgeries resumed across the country and volumes mostly returned to pre-pandemic monthly levels by the end of the year. We also found that there was an increase in the proportion of hip and knee replacements done as day surgery, with 4% in 2020 versus 1% in 2019, and patients undergoing day surgery replacement for osteoarthritis were older, with a median age of 64 for hip patients and 65 for knee patients, versus 63 for both joints the previous year.

As a result of the COVID-19 pandemic, there was a notable drop in 2020 of hip and knee replacements performed in Canada. With the demand for joint replacements continuing to grow, the resulting backlog will have an immediate, significant impact on wait lists and patient quality of life. The shift to a greater proportion of joint replacements performed as day surgeries may have an effect on patient outcomes as well shifts in access to care. It will be important to continue monitor patient outcomes following day surgery and the impact on patients for which day surgery was not an option.

Aim. Little is known about microbiological spectrum and resistance patterns as well as the clinical outcome in patients who undergo a repeat first stage procedure as part of a 2-stage revision arthroplasty for the treatment of periprosthetic hip and knee joint infections. Methods. Between 2011 and 2019, a total of 327 2-stage revision arthroplasties were performed on 312 patients with PJI of the knee and hip at our institution. We performed a retrospective analysis of all patients, who underwent a repeat first stage procedure regarding re-revision rate, host factors, culture negative and positive stages, monomicrobial and polymicrobial infections as well as microbiological spectrum and antimicrobial resistance patterns. Results. Overall, 52/312 (16.7%) patients (27 knee/25 hip) underwent a repeat first stage procedure. There were 35/52 (67.3%) culture positive first, 17/52 (32.7%) culture positive repeat first and 12/52 (23.1%) culture positive second stage procedures. In 13/52 (25%) patients a re-revision surgery was necessary at a median follow-up of 46.8 months (range, 12.2 to 93.3 months). High re-revision rates (10/12 [83.3%]) were found in patients with culture positive second stage and low re-revision rates (3/40 [7.5%]; p<0.01) were found in patients with culture negative second stage. The microbiological spectrum changed in 9/11 (81.8%) patients between culture positive first and repeat first stage, in 3/4 (75%) patients between culture positive repeat first and second stage and in 5/6 (83.3%) between culture positive second stage and subsequent re-revision surgery. Moreover, the antimicrobial resistance pattern changed in 6/9 (66.7%) of persistent microorganisms. Conclusion. Microbiological results during first, repeat first and second stage procedures significantly impacted the re-revision rates and changes in microbiological spectrum and resistance patterns between stages are common. However, if eradication of the microorganism at second stage can be accomplished, low re-revision rates can be achieved, even in patients who require a repeat first stage procedure

Proximal femoral focal deficiency is a congenital disorder of malformation of the proximal femur and/or the acetabulum. Patients present with limb length discrepancy and clinical features along a spectrum of severity. As these patients progress through to skeletal maturity and on to adulthood, altered biomechanical demands lead to progression of arthropathy in any joint within the lower limb. Abnormal anatomy presents a challenge to surgeons and conventional approaches and implants may not necessarily be applicable. We present a case of a 62-year-old lady with unilateral proximal femoral focal deficiency (suspected Aitken Class A) who ambulated with an equinus prosthesis for her entire life. She presented with ipsilateral knee pain and instability due to knee arthritis but could not tolerate a total knee arthroplasty due to poor quadriceps control. A custom osteointegration prosthesis was inserted with a view to converting to the proximal segment to a total hip replacement if required. The patient went on to develop ipsilateral symptomatic hip arthritis but altered acetabular anatomy required a custom tri-flange component (Ossis, Christchurch, New Zealand) and a custom proximal femoral component to link with the existing osseointegration component (Osseointegration Group of Australia, Sydney, Australia) were designed and implanted. The 18 month follow up of the custom hip components showed that the patient had Oxford hip scores that were markedly improved from pre-operatively. Knee joint heights were successfully restored to equal when the patient's prosthesis was attached. The patient describes feeling like “a normal person”, walks unaided for short distances and can ambulate longer distances with crutches. Advances in design and manufacture of implants have empowered surgeons to offer life improving treatments to patients with challenging anatomy. Using a custom acetabular tri-flange and osseointegration components is one possible solution to address symptomatic ipsilateral hip and knee arthropathy in the context of PFFD in adulthood

Purpose. Investigating the effects of femoral stem length on hip and knee muscle strength. Methods. The study included 20 patients having undergone total knee prostheses (TKP) due to coxarthrosis and 10 healthy subjects. Of the 20 patients, 10 underwent conventional TKP and 10 had Thrust Plate Prothesis (TPP). For the assessment of the patients’ muscle strength of operated and non-operated hips (Gl. medius and Gl. Maximus) and knees (Quadriceps Femoris-QF), the Hand-Held Dynamometer (HHD) was used. Results. A significant difference was observed in the muscle strength of Gl. medius in TPP patients and of Gl. maksimus in conventional TKP patients (p <0.05). Compared to the healthy group, only hip muscle strength decreased in TPP patients, but both hip and knee muscle strengths decreased in conventional TKP patients (p <0.05). Conclusion. A decrease in hip and knee muscle strengths was determined in the TPP and conventional THA patients, compared to healthy subjects. Compared to the bone protective prosthetic systems (eg TPP), a significant difference is observed in the QF muscle strength in intramedullary prosthesis applications. This data may be used in planning the treatment of patients with hip arthroplasty

Introduction. Prosthetic joint infection (PJI) is the leading cause of failure of primary and revision hip and knee arthroplasty. It is challenging condition which represents a growing burden on hospital resources. In-patient hospital stay for antibiotic therapy post-operatively is costly and access to out-patient IV therapy (OPAT) varies between regions. In a tertiary referral centre for revision and infection, the suitability and cost-effectiveness of Dalbavancin was reviewed as a “single-shot” therapy following DAIR or revision lower limb arthroplasty for PJI. Methods & Materials. A prospective service evaluation was carried out for consecutive patients treated for PJI of the hip or knee who received Dalbavancin. Treatment was indicated by Consultant Microbiologist advice within an MDT setting where clinical or patient factors made alternative therapies eg. OPAT inappropriate. Service-level data was collected to allow calculation of bed-day savings compared to a traditional 14-day course of IV treatment. Readmission rates to the trust within 30 days were reviewed as a marker of clinical efficacy and safety. Results. 12 patients received dalbavancin for PJI. Mean bed-day saving was 6.9 (SD 3.7) per patient. A total of 83 bed days were saved compared to traditional treatment and there was a modest cost-benefit. There were no adverse reactions noted and no readmissions within 30 days. Discussion. The safety and efficacy of dalbavancin has been demonstrated in recent literature, but the impact that it can have on health-care costs and in-patient burden has not been explored. In addition, the success of out-patient therapy relies on patient engagement. In patients with co-existing cognitive difficulty or alcohol/substance use Dalbavancin offers an attractive alternative. Conclusions. The results of our pilot suggest that IV Dalbavancin is cost-effective as part of the treatment strategy for PJI and can lead to significant bed-day savings, which can assist in patient flow and departmental efficiency

Aim of the study: Prosthetic joint infection (PJI) is a feared complication of total joint arthroplasties. Several strategies were developed to treat it. The purpose of our study was to compare treatment strategies for PJI treatment presented in the literature. Materials and Methods: We found more than 5000 documents in databases MEDLINE and EMBASE concerning this topic, published between January 1960 and November 2006. Using two-phase selection, 382 relevant articles were chosen, full texts were obtained for 302 of them (79%), and 77 studies was included into the analysis according to inclusion criteria (a total of 645 hips and 1145 knees). There were compared two-stage surgery, one-stage surgery, removal of prosthesis, and long-term antibiotic therapy in hip PJI, and two-stage surgery, debridement, arthrodesis, and long-term antibiotic therapy in knee PJI. The rate of PJI recurrence was a primary outcome, need for additional surgery was a secondary outcome. Capability index (c), relative risk (RR), and „number needed to treat“(NNT) were calculated for both outcomes under study. Results:. The lowest rate of recurring PJI was reported for two-stage reimplantation (7.4 % in hip, 11 % in knee), followed by one-stage reimplantation in the case of hip PJI (9.2 %), and arthrodesis in the case of knee PJI (15.6 %);. The lowest RR for primary outcome of the study was revealed for two-stage reimplantation at both sites of surgery (RR=0.62 and 0.32, for hip and knee PJI, respectively), followed by one-stage reimplantation at the site of hip (RR=1.07) and knee arthrodesis (RR=0.78);. NNT was negative for two-stage reimplantation at both sites of surgery (NNT= −21.6 and −4.3, for hip and knee PJI, respectively);. Worse outcomes were found for debridement in comparison to long-term antibiotic therapy in terms of recurrence of PJI (RR=4.72 versus 1.20) and need for surgery (RR=4.41 versus 1.31), however, according to capability index (c=0.0317 versus 0.0000) and NNT (2.2 versus 26.3) knee debridement achieved better outcomes than antibiotic therapy. Relative risk for additional surgery was the lowest in the case of two-stage reimplantation (RR=0.47 and 0.36, for hip and knee PJI, respectively), and the highest in the case of long-term antibiotic therapy at the site of hip (RR=6.47). Conclusion: Two-stage management for treatment of PJI had the smallest risk for both PJI recurrence and need for additional surgery in comparison with all other strategies. One-stage hip reimplantation is a less reliable approach, in which it is necessary to strictly respect the indication criteria. Other methods are either less reliable or are associated with high risk of following surgeries, or unacceptable functional results

Prosthetic joint infection continues to remain a diagnostic challenge for unhappy primary arthroplasty of hip and knees. There is increasing dependence upon alpha-defensin test to make key decisions like whether to revise or not & to decide between one-stage versus two-stage. Aim. This study aims to assess diagnostic accuracy of alpha-defensin test in determining prosthetic hip & knee infection and to provide guidance for appropriate use of this novel but expensive investigation. Methods. Retrospective review of all alpha-defensin investigated patients in an orthopaedic institute between February 2015 & March 2017 was performed. Clinical and radiological outcomes including re-infections, re-operations were analysed and alpha-defensin outcomes were compared with that of other available investigations. Results. Of total 52 tests performed (17 hips & 35 knees), 3 were positive. On comparison with intra-operative culture (gold standard), sensitivity is 100%. All suspected prosthetic hip infections have good clinical outcomes following their decisions being made based upon alpha-defensin test. Among the negative knee test results, 6 patients developed signs of infection in the post-operative period, 4 of which have been revised with washout, poly exchange or full revision. Conclusion. No single clinical investigation can accurately predict prosthetic joint infection in revision for suspected infection. Alpha-defensin test, however, is a useful adjunct to intra-operative surgeon's findings & pre-operative investigations to decide for crucial decisions like whether to revise or not & for deciding between single and two stage

Aims

Day-case success rates after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) may vary, and detailed data are needed on causes of not being discharged. The aim of this study was to analyze the association between surgical procedure type and successful day-case surgery, and to analyze causes of not being discharged on the day of surgery when eligible and scheduled for day-case THA, TKA, and mUKA.

Aims

The extended wait that most patients are now experiencing for hip and knee arthroplasty has raised questions about whether reliance on waiting time as the primary driver for prioritization is ethical, and if other additional factors should be included in determining surgical priority. Our Prioritization of THose aWaiting hip and knee ArthroplastY (PATHWAY) project will explore which perioperative factors are important to consider when prioritizing those on the waiting list for hip and knee arthroplasty, and how these factors should be weighted. The final product will include a weighted benefit score that can be used to aid in surgical prioritization for those awaiting elective primary hip and knee arthroplasty.

Aim. To assess the influence of route of antibiotic administration on patient-reported outcome measures (PROMS) of individuals treated for hip and knee infections in the OVIVA multi-centre randomised controlled trial. Method. This study was designed to determine whether oral antibiotic therapy is non-inferior to intravenous (IV) therapy when given for the first six weeks of treatment for bone and joint infections. Of the 1054 participants recruited from 26 centres, 462 were treated for periprosthetic or native joint infections of the hip or knee. There were 243 participants in the IV antibiotic cohort and 219 in the oral cohort. Functional outcome was determined at baseline through to one year using the Oxford Hip/Knee Score (OHS/OKS) as joint-specific measures (0 the worse and 48 the best). An adjusted quantile regression model was used to compare functional outcome scores. Results. Of the 214 participants in the hip sub-group, 110 were randomized to IV antibiotics and 104 to oral. Of the 248 participants in the knee cohort, 133 were treated with IV antibiotics and 115 with oral. The OHS/OKS questionnaire response rate was 68%. Baseline median OHS of the hip sub-group was 14 (Interquartile range [IQR]:8–22) for the IV cohort and 12 (IQR:7–22) for the oral cohort. The one-year median OHS was 35 (IQR: 23–44) for the IV cohort and 27 (IQR:16–40) for the oral cohort with no significant difference between cohorts (p=0.181). The baseline median OKS of the knee sub-group, was 14 (IQR:8–23) for the IV cohort and 12 (IQR:8–21) for the oral cohort. The one-year median OKS was 24 (IQR: 15–35) for the IV cohort and 27 (IQR:17–38) for the oral cohort with a statistically significant difference in favour of oral therapy (p=0.036). Conclusions. At one year, there was improvement in functional outcome of patients treated with either IV or oral antibiotics in this RCT. It suggests that joint function generally improved progressively following the start of treatment irrespective of the route of antibiotic therapy. Functional outcome of patients with hip infections was similar irrespective of the route of antibiotic therapy, whereas there was statistically greater improvement in functional outcome of patients with knee infections treated with oral antibiotics. The PROMS findings of this trial support the clinical findings (i.e. infection eradication rates) and suggest that there is no advantage of using prolonged intravenous therapy as compared to oral therapy in the early treatment of infections around the hip and knee joint