Aims

There is a considerable challenge in treating bone infections and orthopaedic device-associated infection (ODAI), partly due to impaired penetration of systemically administrated antibiotics at the site of infection. This may be circumvented by local drug administration. Knowledge of the release kinetics from any carrier material is essential for proper application. Ceftriaxone shows a particular constant release from calcium sulphate (CaSO₄) in vitro, and is particularly effective against streptococci and a large portion of Gram-negative bacteria. We present the clinical release kinetics of ceftriaxone-loaded CaSO₄ applied locally to treat ODAI.

Aims. Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results. The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion. We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233

Introduction. Debridement, antibiotics, and implant retention (DAIR) for acute prosthetic hip infection is a popular low morbidity option despite less than optimal success rates. We theorized that the delay between DAIR and explantation in failed cases may complicate eradication due to biofilm maturation and entrenchment of bacteria in periprosthetic bone. We ask, what are the results of two-stage reimplantation after a failed DAIR versus an initial two-stage procedure?. Methods. 114 patients were treated with 2-stage exchange for periprosthetic hip infection. 65 were treated initially with a 2-stage exchange, while 49 underwent an antecedent DAIR prior to a 2-stage exchange. Patients were classified according to MSIS host criteria. Failure was defined as return to the OR for infection, a draining sinus, or systemic infection. Results. Treatment failure occurred in 42.9% (21 of 49) of patients treated with an antecedent DAIR. In contrast, treatment failure occurred in only 12.3% (8 of 65) of initial 2-stage procedures (p< 0.001). Relative Risk of return to the OR after a 2-stage reimplantation with an antecedent DAIR compared to initial resection was 4.52 (95% CI 1.71, 11.9). MSIS host grading was similar between groups and did not influence the rate of failure. The DAIR cohort had increased hospitalization length and greater number of operative procedures (p< 0.001). Conclusion. We have shown that if irrigation and debridement fails to treat acute prosthetic hip infection, subsequent attempts at two-stage reimplantation may be compromised. Additionally, in the antecedent DAIR group, the average number of infection-related procedures (5) was nearly twice that of those initially resected (2.7). This by nature implies a significantly greater burden to the patient and cost to the healthcare system

Objectives. Preclinical data showed poly(methyl methacrylate) (PMMA) loaded with microsilver to be effective against a variety of bacteria. The purpose of this study was to assess patient safety of PMMA spacers with microsilver in prosthetic hip infections in a prospective cohort study. Methods. A total of 12 patients with prosthetic hip infections were included for a three-stage revision procedure. All patients received either a gentamicin-PMMA spacer (80 g to 160 g PMMA depending on hip joint dimension) with additional loading of 1% (w/w) of microsilver (0.8 g to 1.6 g per spacer) at surgery 1 followed by a gentamicin-PMMA spacer without microsilver at surgery 2 or vice versa. Implantation of the revision prosthesis was carried out at surgery 3. Results. In total, 11 of the 12 patients completed the study. No argyria or considerable differences in laboratory parameters were detected. Silver blood concentrations were below or around the detection limit of 1 ppb in ten of the 11 patients. A maximum of 5.6 ppb at 48 hours after implantation of the silver spacer, which is below the recommended maximum level of 10 ppb, was found in one patient. No silver was detected in the urine. Drainage fluids showed concentrations between 16.1 ppb and 23.3 ppb at 12 hours after implantation of the silver spacers, and between 16.8 ppb to 25.1 ppb at 48 hours after implantation. Pathohistological assessment of the periprosthetic membrane did not reveal any differences between the two groups. Conclusion. Microsilver-loaded gentamicin-PMMA spacers showed good biocompatibility and the broad antimicrobial activity warrants further clinical research to assess its effectivity in reducing infection rates in prosthetic joint infection. Cite this article: V. Alt, M. Rupp, K. Lemberger, T. Bechert, T. Konradt, P. Steinrücke, R. Schnettler, S. Söder, R. Ascherl. Safety assessment of microsilver-loaded poly(methyl methacrylate) (PMMA) cement spacers in patients with prosthetic hip infections: Results of a prospective cohort study. Bone Joint Res 2019;8:387–396. DOI: 10.1302/2046-3758.88.BJR-2018-0270.R1

Introduction

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM: EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI.

Hip prosthetic joint infection (PJI) is a debilitating complication following joint replacement surgery, with significant impact on patients and healthcare systems. The INFection ORthopaedic Management: Evidence into Practice (INFORM:EP) study, builds upon the 6-year INFORM programme by developing evidence-based guidelines for the identification and management of hip PJI.

A panel of 21 expert stakeholders collaborated to develop best practice guidelines based on evidence from INFORM \[1\]. An expert consensus process was used to refine guidelines using RAND/UCLA criteria. The guidelines were then implemented over a 12-month period through a Learning Collaborative of 24 healthcare professionals from 12 orthopaedic centres in England. Qualitative interviews were conducted with 17 members of the collaborative and findings used to inform the development of an implementation support toolkit. Patient and public involvement contextualised the implementation of the guidelines. The study is registered with the ISCRTN (34710385).

The INFORM guidelines, structured around the stages of PJI management, were largely supported by surgeons, although barriers included limited awareness among non-surgical team members, lack of job planning for multidisciplinary teams, and challenges in ensuring timely referrals from primary care. Psychological support for patients was identified as a critical gap. Advanced Nurse Practitioners and multidisciplinary team (MDT) coordinators were seen as potential bridges to address these knowledge gaps. The guidelines were also viewed as a useful tool for service development.

This study presents the first evidence-based guidelines for hip PJI management, offering a comprehensive approach to prevention, treatment, and postoperative care. Effective implementation is crucial, involving wider dissemination amongst primary and community care, as well as non-specialist treatment centres. Further resources are needed to ensure job planning for MDTs and psychological support for patients. Overall, this study lays the foundation for improved PJI management, benefiting patients and healthcare systems.

Aims

Current diagnostic tools are not always able to effectively identify periprosthetic joint infections (PJIs). Recent studies suggest that circulating microRNAs (miRNAs) undergo changes under pathological conditions such as infection. The aim of this study was to analyze miRNA expression in hip arthroplasty PJI patients.

Two-stage reimplantation is currently the most widely accepted method of treatment for a periprosthetic hip infection. However, it remains controversial whether the treatment protocol may be equally effective in the eradication of resistant microorganisms. We compared the results of two-stage reimplantation performed for periprosthetic hip infection caused by resistant microorganisms with those performed for periprosthetic hip infection caused by non-resistant microorganisms. We reviewed a consecutive series of 32 patients (32 hips) who had a culture-proven deep infection at the site of hip arthroplasty and were treated by a two-stage reimplantation protocol. Based on the antibiotic sensitivities of the infecting microorganisms, the patients were divided into two groups. Resistant microorganism group consisted of 20 patients who had an infection with antibiotic-resistant bacterial strains (methicillin-resistant Staphylococcus aureus in 11 and methicillin-resistant Staphylococcus epidermidis in 9). Non-resistant microorganism group consisted of 12 patients who had an infection with antibiotic-sensitive bacterial strains. The treatment was considered a failure if the patient had a persistent infection after the first-stage procedure or a recurrence of infection after reimplantation. The mean duration of follow-up after the index procedure was 45 months (24 to 123). Among the entire series of the 32 patients, the second-stage reimplantation was able to be performed in 29 patients (91%) and the remaining three went on to a permanent resection of the hip because of persistent infections. After the two-stage reimplantation, four patients had a recurrence of infection (relapse of infection with the same microorganism in three and reinfection with different resistant microorganism in one). Thus, overall treatment failure rate was 22% and all these failures occurred among patients with resistant microorganisms. Treatment failure rate of 35% in resistant microorganism group was significantly higher than that of 0% in the non-resistant microorganism group (p = 0.029). None of the variables evaluated in this study was found to be significantly associated with the treatment failure in the resistant microorganism group. Current two-stage reimplantation protocol showed a high rate of treatment failure in our patients who had periprosthetic hip infection caused by methicillin-resistant bacterial strains. Further study is needed to develop optimal treatment strategy for this difficult-to-treat condition

Staged revision arthroplasty for the periprosthetic hip infection is the accepted mode of treatment. Unfortunately, the first stage revision compromises the patient’s function secondary to inability to weight-bear. Pros-theses coated with antibiotic-loaded cement have been adapted to improve function but have failed in larger femoral defects. This implant and technique described improves patient mobility and decreases morbidity as compared to conventional techniques. The purpose of this study was to find an implant to accommodate most femoral defects and to be readily available for managing periprosthetic hip infections. A prospective study was performed comparing the PROSTALAC(DePuy, IN) implant (Group I) to a Solution(DePuy, IN) implant (Group II) covered in antibiotics for management of the first stage. All patients had a confirmed pyogenic gram positive or gram negative infection. Fifty-two patients were compared with each group being matched by their femoral defect type (Paprosky: Type I and II: 24, Type III:20, Type IV: 8). Follow-up was for a minimum of thirty-six months. All patients were encouraged to weight bear as tolerated. One recurrence of infection occurred after a second stage revision in Group I. Cost of the implant averaged $700 cheaper in Group II. More significant was the fact that the average length of hospital stay was decreased in Group II by seven days and forty-seven days for the Type III and Type IV femurs respectively. All patients in Group I received a second stage revision. Five of the Group II patients refused a second stage revision secondary to their satisfactory function and had better post-op function. An alternative treatment for staged periprosthetic hip infections is proposed which can decrease hospital stay, improve function, and allow routine implant use for its implementation

Aim. Two stage revision is the most commonly used surgical treatment strategy for periprosthetic hip infections (PHI). The aim of our study was to assess the intra- and postoperative complications during and after two stage revision using resection arthroplasty between ex- and reimplantation. Method. In this retrospective cohort study, all patients treated with a two stage revision using resection arthroplasty for PHI were included from 2008 to 2014. During the first stage, the prosthesis was removed resulting in a resection arthroplasty without the use a PMMA spacer. During second stage, (cemented or uncemented) reimplantation of the hip prosthesis was performed. The cohort was stratified into two groups according to the length of prosthesis-free interval (≤10 weeks and >10 weeks). Data on complications during explantation, prosthesis-free interval, reimplantation, and after reimplantation was collected. The overall complication rate between both groups was compared using the chi-squared test. The revision-free and infection-free survival was estimated using Kaplan-Meier survival analysis. Results. Overall, 93 patients with hip PJI treated with two-stage revision performing resection arthroplasty were included, 49 had a prosthesis-free interval of ≤10 weeks, and 44 an interval of >10 weeks. A total of 146 complications was documented in the cohort. Patients were followed-up for a mean duration of 42.7 months, range: 13.1 – 104.6 months. Blood loss during reimplantation [n=25], blood loss during explantation [n=23], persistent infection during prosthesis-free interval [n=16], leg length discrepancy [n=13], and reinfection [n=9] were the most common complications. No complication showed a statistically significant difference between both groups except for wound healing disorder after reimplantation, which was more often reported in the group with > 10 weeks interval (p=0.009). A statistically significant increase of periprosthetic bone fractures (p=0.05), blood loss (p=0.039), and total number of complications (p=0.008) was seen with increasing acetabular bone defects (after Paprosky). Infection-free survival rate at 24 months was 93.9% (95% CI: 87.2 – 100) in the group with ≤10 weeks interval and 85.9% (95% CI: 75.4 – 96.4) with an interval of > 10weeks. Conclusions. After two years of follow-up, the infection-free survival rate using resection arthroplasty during two stage revision for PHI was higher in the group with ≤10 weeks interval compared to the group with >10 weeks interval. The most common complications during and after a two stage revision using resection arthroplasty were blood loss during the two surgeries, persistent infection during the prosthesis-free interval, leg length discrepancy, and reinfection

We report the outcomes ten to fifteen years after two stage revision for hip infection in one hundred and three patients. All patients or their next of kin were contacted to determine their current functional status and whether they had required repeat surgery or had recurrent infection. The Oxford-12, SF-12, and WOMAC questionnaires were administered. A comprehensive chart review was undertaken to review the infective organisms, surgery, approach, complications, and need for further revision surgery. Ten patients had re-infection, six of whom responded to repeat surgery with no further sequelae. Two patients required resection arthroplasty, one patient underwent hip disarticulation after eventual failure of treatment and bone loss, and one immunocompromised patient developed osteomyelitis and was subsequently lost to follow-up. Long-term success rate for two stage- revision is thus 90.3%, or 96.1% with additional surgery. Since then, three patients required revisions for aseptic loosening, one for recurrent dislocation. We were able to follow up forty-one patients, 85 % of whom provided health-related quality of life outcome scores. Thirty-nine patients were deceased, with their outcome confirmed via their last follow-up or with family members, for a total follow-up rate of 78 %. Twenty-three patients were lost to follow-up, but did not undergo further surgery or have reinfections treated at our centre. Two-stage revision for hip infection, which includes an interim prosthesis of antibiotic loaded cement, offers a predictable and lasting solution for patients with this difficult problem

Aim

The cut-off values for synovial fluid leukocyte count and neutrophils differential (%PMN) for differentiating aseptic from septic failure in total knee arthroplasties were already defined in the past. Our goal was to determine the cut-off values for synovial fluid leukocyte count and %PMN in failed total hip arthroplasties (THA).

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip replacement. Over 1,000 operations are performed annually in the United Kingdom for PJI following hip replacement, using either one- or two-stage revision arthroplasty. It is unclear which is preferred by patients and which has the best long-term outcome. This qualitative study aims to describe patient experiences of treatment and recovery following one- and two-stage revision arthroplasty for PJI within the context of a pragmatic randomised controlled trial comparing these two approaches. Semi-structured interviews were conducted with 32 patients undergoing one- or two-stage revision treatment for PJI as part of a UK multi-centre randomised controlled trial. Patients were recruited from 12 participating National Health Service (NHS) Orthopaedic Departments and were interviewed 2–4 months after their first revision surgery and again approximately 18 months later. Final sample size was justified on the basis of thematic saturation. All patients consented to the interview being audio-recorded, transcribed, anonymised and analysed using an inductive thematic approach. Ethical approval was provided by NRES Committee South-West Frenchay, 14/SW/116. Patients in both the one- and two-stage treatment groups described prolonged hospital stays, with burdensome antibiotics and brief physiotherapy treatment. However, following discharge home and during recovery, participants undergoing two-stage revision with an ‘empty hip' or with a spacer reported being physically restricted in almost every aspect of their daily life, resulting in inactivity and confinement to home. Mobility aids were not sufficiently available through the health service for these patients. A key difference is that those with a spacer reported more pain than those without. Approximately one year following their second-stage revision, participants described being more independent and active, but two directly attributed muscle weakness to the lengthy period without a hip and described resulting falls or dislocations that had complicated their recovery. In contrast, those undergoing one-stage revision and CUMARS appeared to be more alike, reporting better mobility, functionality and independence, although still limited. Participants in these groups also reported minimal or no pain following their revision. A key difference between CUMARS and one-stage revision was the uncertainty of whether a second operation was necessary, which participants described as “hanging over them”, while those in the two-stage empty hip or spacer group described a more positive anticipation of a second definitive operation as it marked an end to what was described as a detachment from life. Our findings highlight the differences between patient experiences of recovery following revision arthroplasty, and how this is influenced by the surgical approach and presence or lack of spacers. An understanding of lived experiences following one- and two-stage surgical interventions will complement knowledge about the clinical effectiveness of these different types of revision surgery.

Aim of the study: The outcomes of 50 consecutive patients with chronic periprosthetic total hip arthroplasty infections were evaluated based on a staging system developed at the authors’ institution. The staging system includes three categories: infection type (acute versus chronic), systemic host grade, and local extremity grade. Methods: The initial treatment plan was a two-stage resection followed by reimplantation if clinically indicated. Treatment was modified for each patient according to how the patient responded to initial debridement. The average follow-up was 23.2 months (range, 0–74 months). Of the 50 patients, 29 had reimplantation with a total hip arthroplasty (58%), 17 patients had permanent resections (34%), and four patients had amputations (8%). Five patients died (10%). Fifteen patients had muscle flap transfers into the hip for soft tissue coverage. Results: Significant correlations were seen with the staging system and outcome parameters. Patients who were very medically ill were far more likely to die or have their leg amputated. Conversely, healthier patients were more likely to have successful reimplantation. A strong correlation was seen with a compromised local wound and the need for muscle. ap transfer. Complication rates were strongly related to worsening medical condition and a worsening local wound. Conclusion: Based on these results, a staging system for periprosthetic infection is a useful tool that with additional refinement will provide more objective evaluation of treatment methods for periprosthetic hip infection in the future

Introduction

Two-stage reimplantation for prosthetic joint infection (PJI) of the hip is the standard of care with a 5–10% recurrence at a minimum two-year follow-up. Compiling outcomes data for this standard of care is necessary in order to characterize long-term reinfection risk and the culpable microbiology. The purpose of this study was to determine the long-term success of two-stage reimplantation and identify the factors that affected the success.

Next-generation sequencing (NGS) is a well-established technique for amplification and sequencing of DNA and has recently gained much attention in many fields of medicine. Our aim was to evaluate the ability of NGS in identifying the causative organism(s) in patients with periprosthetic joint infection (PJI).

In this prospective study samples were collected from 78 revision total hip arthroplasties. Synovial fluid, deep tissue and swabs were obtained at the time of surgery and shipped to the laboratory for NGS analysis. Deep tissue specimens were also sent to the institutional lab for culture. PJI was diagnosed using the Musculoskeletal infection society (MSIS) definition of PJI.

Thirty-four revisions were considered infected; culture was positive in 25 of these (25/34, 73.5%), while NGS was positive in 26 (26/34, 76.4%). Among the positive cultures, complete concordance between NGS and culture in 21 cases (21/25, 84.0%). 4 cases were discordant. Among these cases, 3 cases were culture-positive and NGS-negative, while 1 was both positive on NGS and culture for disparate organisms. Among the 9 cases of culture-negative PJI(CN-PJI), NGS was able to identify an organism in 4 cases (4/9, 44.4%). The remaining 5 cases were negative on both NGS and culture (5/9, 55.6%). Forty-four revisions were considered to be aseptic; NGS exclusively identified microbes in 7 of 44 “aseptic” revisions (15.9%) and culture exclusively isolated an organism in 3 of 44 cases (6.8%). Both NGS and culture were positive in 1 of case however the result was discordant. The remaining cases (33/44, 75.0%) were both NGS and culture negative. NGS detected several organisms in most positive samples, with a greater number of organisms detected in aseptic compared to septic cases (7 vs. 3.7, respectively).

NGS may be a promising technique for identifying the infecting organism in PJI. Our findings suggest that some cases of PJI may be polymicrobial that escape detection using conventional culture.

The unwell child with an acutely irritable hip poses a diagnostic dilemma. Recent studies indicate that pericapsular myositis may be at least as common as joint infection in the septic child. MRI might therefore be a critical first step to avoid unnecessary hip drainage surgery in the septic child with hip symptoms.

We reviewed our own experience with MR imaging in this setting.

We searched our PACS system to retrieve MRI scans performed for children with suspected hip sepsis from August 2008 to August 2014 using the following terms: hip, septic arthritis, osteomyelitis, mysositis, abscess, femur, acetabulum. 56 cases fulfilled inclusion criteria that included acute presentation with hip symptoms and 2 or more Kocher criteria for septic arthritis. Recent unsuccessful hip washout was not a contra-indication.

56 patients presented with acute infection around the hip. 47 (84%) had MRI scans before any surgical intervention and 9 (16%) had scans promptly following unsatisfactory hip washout with failure to improve.

20 (36%) were found to have pericapsular myositis. In this group, the infection commonly involved the iliopsoas (4), gluteal (4), piriformis (5) or obturator (7) muscles. 15 (27%) children had proximal femoral or acetabular osteomyelitis and 8 (14%) were diagnosed with septic arthritis. The 13 (23%) remaining scans did not show infection around the hip.

This study confirms a high rate of extracapsular foci in septic children presenting with hip irritability. Less than 20% had actual septic arthritis in this series. While drainage of a septic joint should never be delayed in the face of a large joint effusion with debris on US, there is a clear role for MRI scanning in the acute setting when the diagnosis is less certain.

Infection after total hip arthroplasty is a rare but potentially devastating complication. The most common pathogens responsible for these infections are gram positive bacteria. Infection caused by fungi is uncommon. There are few reports of prosthetic joint infection caused by Candida species, and there has no report of implant preservation.

We experienced the case of a patient with Candida arthritis who underwent total hip arthroplasty for hip arthrosis, and successfully could preserved prosthetic joint.

A 60 year-old woman underwent total hip arthroplasty in September 2014. She had had the past of sepsis by the Candida after surgery of the duodenal cancer. After four weeks in total hip arthroplasty, she made clinic visits. Her chief complaints were low-grade fever of 1 week's duration and discharge from operative scar for THA. The patient underwent arthrocentesis of the left hip. The culture was positive for Candida tropicalis.

Operation of surgical debridement and liner change was performed as soon as possible. After operation, the patient was treated with fluconazole intravenously for 28 days.

She has continued to taken fluconazole by mouth. Reactivation of infection have not been in her left hip.

We reported the case of a patient with Candida arthritis who underwent total hip arthroplasty. Prosthetic joint could have preserved because of early detection for infection. This is the first report of preservating implant after Candida infection in total hip arthroplasty.

Introduction

Single-stage resection and reimplantation for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is of recent interest, yet outcomes may be skewed by selected populations with healthier patients and less virulent organisms. This study quantified the effectiveness of a contemporary, evidence-based and standardized two-stage treatment protocol in patients with THA PJI including chronically infected, poor hosts.

Introduction: The incidence of tuberculosis has increased by almost 30% annually in the UK. Orthopaedic surgeons are more likely to encounter patients affected with Mycobacterium tuberculosis [MTB]. We have reviewed the surgical and medical management of cases of MTB infecting prosthetic hip joints in patients without previous tuberculosis.

Report: A 59 year old Caucasian woman presented to us with apparent osteoarthritis hip. X-rays confirmed osteoarthritis but also revealed a lytic lesion in the greater trochanter and erosion of the superior cortex of the femoral neck. The patient had no prior history of exposure to tuberculosis and no evidence of pulmonary or osteoarticular tuberculosis. The patient was investigated preoperatively with blood tests, bone scan, CT scan, CT guided FNAC, and core biopsy. None of these showed any specific diagnostic features. She underwent a total hip replacement and was asymptomatic up to 15 months post-op when she presented with pain in the joint with an abscess over the gluteal region. The abscess was drained and special media culture grew MTB. We used 4-drug therapy for 12 months with retention of the prosthesis and a good functional result.

Discussion: Infected total hip replacement presents a management challenge and surgeons should have a high index of suspicion for Tuberculosis in recalcitrant infections where smears from infected joints are negative. The infection of a total hip replacement with MTB in patients without previous tuberculosis is very uncommon. Only 12 cases have been reported in a search of English language literature from 1966–2005.

We have analysed the wide variation in the management of these cases. The majority of authors in our review resected or revised the infected prosthesis. We are of the opinion that if the infection is clinically under control and the prosthesis is stable, medical treatment alone should suffice.