Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We investigated the rates of revision surgery for the treatment of PJI following primary and revision hip and knee replacement, explored time trends, and estimated the overall surgical burden created by PJI. We analysed the National Joint Registry for England and Wales for revision hip and knee replacements performed for a diagnosis of PJI and their index procedures from 2003–2014. The index hip replacements consisted of 623,253 primary and 63,222 aseptic revision hip replacements with 7,642 revisions subsequently performed for PJI; for knee replacements the figures were 679,010 primary and 33,920 aseptic revision knee replacements with 8,031 revisions subsequently performed for PJI. Cumulative incidence functions, prevalence rates and the burden of PJI in terms of total procedures performed as a result of PJI were calculated. Revision rates for PJI equated to 43 out of every 10,000 primary hip replacements (2,705/623,253), i.e. 0.43%(95%CI 0.42–0.45), subsequently being revised due to PJI. Around 158 out of every 10,000 aseptic revision hip replacements performed were subsequently revised for PJI (997/63,222), i.e. 1.58%(1.48–1.67). For knees, the respective rates were 0.54%(0.52–0.56) for primary replacements, i.e. 54 out of every 10,000 primary replacements performed (3,659/679,010) and 2.11%(1.96–2.23) for aseptic revision replacements, i.e. 211 out of every 10,000 aseptic revision replacements performed (717/33,920). Between 2005 and 2013, the risk of revision for PJI in the 3 months following primary hip replacement rose by 2.29 fold (1.28–4.08) and after aseptic revision by 3.00 fold (1.06–8.51); for knees, it rose by 2.46 fold (1.15–5.25) after primary replacement and 7.47 fold (1.00–56.12) after aseptic revision. The rates of revision for PJI performed at any time beyond 3 months from the index surgery remained stable or decreased over time. From a patient perspective, after accounting for the competing risk of revision for an aseptic indication and death, the 10-year cumulative incidence of revision hip replacement for PJI was 0.62%(95%CI 0.59–0.65) following primary and 2.25%(2.08–2.43) following aseptic revision; for knees, the figures were 0.75%(0.72–0.78) following primary replacement and 3.13%(2.81–3.49) following aseptic revision. At a health service level, the absolute number of procedures performed as a consequence of hip PJI increased from 387 in 2005 to 1,013 in 2014, i.e. a relative increase of 2.6 fold. While 70% of those revisions were two-stage, the use of single stage revision increased from 17.6% in 2005 to 38.5% in 2014. For knees, the burden of PJI increased by 2.8 fold between 2005 and 2014. Overall, 74% of revisions were two-stage with an increase in use of single stage from 10.0% in 2005 to 29.0% in 2014. Although the risk of revision due to PJI following hip or knee replacement is low, it is rising. Given the burden and costs associated with performing revision joint replacement for prosthetic joint infection and the predicted increased incidence of both primary and revision hip replacement, this has substantial implications for service delivery

Periprosthetic joint infections (PJI) continue to be a diagnostic challenge for orthopedic surgeons. Chronic PJI are sometimes difficult to diagnose and occasionally present in a subclinical fashion with normal CRP/ESR and/or normal joint aspiration. Some institutions advocate for routine use of intraoperative culture swabs at the time of all revision surgeries to definitively rule out infection. The purpose of this study is to determine whether routine intraoperative cultures is an appropriate and cost effective method of diagnosing subclinical chronic PJI in revision joint replacement patients with a low clinical suspicion for infection. We performed a retrospective chart review and identified 33 patients that underwent revision hip or knee replacement from a single surgeon over a five-month period. The AAOS guidelines for preoperative PJI workup were followed. 13 patients were diagnosed preoperatively with infection and excluded from the study. 20 patients underwent revision joint replacement and three separate cultures swabs were taken for each patient to help in determining true-positive cultures. Infectious Disease was consulted for all patients with any positive culture. Culture results were reviewed. At our hospital, the cost billed to insurance for a single culture is $1,458.58. We did not calculate the cost of the consultant fee. Three (15%) of the 20 revision arthroplasty patients had a single positive culture. Infectious Disease consultants diagnosed all three of these positive cultures as contaminants. None of the patients had a true-positive intraoperative culture. The total cost billed by the hospital to obtain these cultures in all 20 patients was $87,514.80. In our study, obtaining a set of three intraoperative cultures for those patients with a negative preoperative infection workup was not only cost prohibitive but did not diagnose a single subclinical infection. Studies to find other more reliable, accurate, and cost effective alternatives to diagnose PJI are warranted. In patients undergoing revision hip or knee arthroplasty with a low preoperative clinical suspicion for infection, it does not seem that routine intraoperative culture swabs are necessary or cost effective method for diagnosing subclinical periprosthetic joint infection

Introduction. Infection after total joint arthroplasty is a challenging problem. Clinical symptoms, Erythrocyte sedimentation rate, C-reactive protein level, and cultures of synovial fluid obtained by means of percutaneous aspiration are commonly used to rule out the possibility of persistent infection before reimplantation. However, the sensitivity and specificity of the tests are low. Some authors have suggested that frozen-section analysis should always be performed during the reimplantation in order to rule out persistent infection. Methods. Retrospective review of 126 revision hip and knee arthroplasty procedure performed from 2002 - 2007 in Derriford Hospital, Plymouth NHS truts, UK. Frozen section was performed in 86 procedures out of the 126 procedures reviewed(68.2 %). A positive frozen section with more than 10 PNLs per HPF was compared with intra operative cultures results. The preoperative CRP results were recorded as well. Results. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for frozen section were 45.5 %, 93.1%,50%, 95%, 94% respectively. Combining the intraoperative frozen section with the CRP results, the specificity was 100%. Discussion. A negative finding on intra operative analysis of frozen sections has a high predictive value with regard to ruling out the presence of infection; However, the sensitivity of the test for the detection of persistent infection is low. The data support the conclusion that the Frozen Section is reasonably specific but not a sensitive. Combining it with the preoperative CRP results led to increasing the specificity to 100% in our series

Aim

”There is not a lot of data of the frequency and impact of unwanted events including glove perforation, contamination of the surgical field (drape perforation, laceration, detachment, bone bounced back from an unsterile object), unsterile object in the surgical field (hair, sweat droplet…), defecation, elevated air temperature, and others. Mishaps occur in every surgical theatre. These events should influence the surgical site infection rate but it is not clear to what extent. We wanted to calculate the frequency and measure the impact of these events on the infection and revision rate of the relative patients.”

Aims. The aim of this study was to conduct evidence synthesis on the available published literature of the impact of the training status of the operating surgeon (trainee vs. consultant) on the survival and revision rate of primary hip and knee replacements. Patients and Methods. We conducted a systematic review according to Cochrane guidelines. Separate searches were performed for hip and knee replacements, with meta-analysis and presentation of results in parallel. We searched MEDLINE and Embase databases from inception to 17 September 2019 and included controlled trials and cohort studies reporting implant survival estimates, or revision rates of hip and knee replacements according to the grade of the operating surgeon. This study was registered with PROSPERO (CRD42019150494). Results. 8 studies (5 hip papers and 3 knee papers) met the inclusion criteria. There was no significant difference in the survival estimates for total hip replacements (THRs) performed by trainees compared to consultants at 5-years follow-up (97.9% vs 98.1%, p = 0.74). Furthermore, there was no significant difference in the revision rate of THRs performed by trainees and consultants at both 5 and 10-year intervals of follow-up (relative risk [RR]: 5yrs = 0.88 (95% CI: 0.46, 1.70; P = 0.71); 10yrs = 0.68 (95% CI: 0.37, 1.26; P = 0.22)). There was no significant difference in the survival estimates at 10-years for total knee replacements (TKRs) performed by trainees compared to consultants (96.2% vs 95.1%, p=0.49). Conclusion. There is no evidence in the existing literature that trainee surgeons have worse outcomes than their consultant colleagues, in terms of the survival, or rate of revision of hip and knee replacements at 5–10 years follow-up. This may mean that there is genuinely no difference or that, in the context of contemporary training programmes, appropriate case-mix selection and supervision of trainees is currently employed

With an ageing population and an increasing number of primary arthroplasties performed, the revision burden is predicted to increase. The aims of this study were to 1. Determine the revision burden in an academic hospital over a 11-year period; 2. identify the direct hospital cost associated with the delivery of revision service and 3. ascertain factors associated with increased cost. This is an IRB-approved, retrospective, single tertiary referral center, consecutive case series. Using the hospital data warehouse, all patients that underwent revision hip or knee arthroplasty surgery between 2008-2018 were identified. 1632 revisions were identified (1304 patients), consisting of 1061 hip and 571 knee revisions. The majority of revisions were performed for mechanical-related problems and aseptic loosening (n=903; 55.3%); followed by periprosthetic joint infection (n=553; 33.9%) and periprosthetic fractures (176; 10.8%). Cost and length of stay was determined for all patient. The direct in-hospital costs were converted to 2020 inflation-adjusted Canadian dollars. Several patients- (age; gender; HOMR- and ASA-scores; Hemoglobin level) and surgical- (indication for surgery; surgical site) factors were tested for possible associations. The number of revisions increased by 210% in the study period (2008 vs. 2018: 83 vs. 174). Revision indications changed over study period; with prevalence of fracture increasing by 460% (5 in 2008 vs. 23 in 2018) with an accompanying reduction in mechanical-related reasons, whilst revisions for infection remained constant. The mean annual cost over the entire study period was 3.9 MMCAD (range:2.4–5.1 MMCAD). The cost raised 150% over the study period from 2.4 MMCAD in 2008 to 3.6 MMCAD. Revisions for fractured had the greatest length of stay, the highest mean age, HOMR-score, ASA and cost associated with treatment compared to other revision indications (p < 0 .001). Patient factors associated with cost and length of stay included ASA- and HOMR-scores, Charlson-Comorbidity score and age. The revision burden increased 1.5-fold over the years and so has the direct cost of care delivery. The increased cost is primarily related to the prolonged hospital stay and increased surgical cost. For tertiary care units, these findings indicate a need to identify strategies on improving efficiencies whilst improving the quality of patient care (e.g. efficient ways of reducing acute hospital stay) and reducing the raise of the economic burden on a publicly funded health system

Two stage revision for infection is considered the gold standard with a success rate of 80–90%. Overall functional outcomes of these patients are commonly overlooked. There is a trend towards single stage revision to improve functional outcomes.

We examined the functional scores of 2 stage revision for total hip arthroplasty (THR) and total knee arthroplasty (TKR). 72 revisions were identified over 9 years: 30 THR and 42 TKR. Two year survivorship was 96% in THR revision and 88% TKR revision. Five year survival was 83% and 84% respectively. 50 patients (without recurrence of infection) had recorded functional scores at a minimum of 1 year.

The mean Harris-hip score (HHS) of THR was 75 (21 patients) prior to developing symptoms of infection. Once infected, the mean score fell to 46. At 1 year post revision it returned to 77. At 3 years HHS of 78 (12 patients) and at 5 yrs 62 (3 patients).

The mean knee society score (KSS) of TKR was 66 (29 patients) prior to developing symptoms of infection. Once infected, the mean score fell to 34. At 1 year post revision it returned to 73. At 3 years KSS of 76 (16 patients) and at 5 years 62 (10 patients).

We conclude that functional scores of staged revisions of infected THR and TKR return to pre-morbid levels within a year of completing the second stage. Although single stage revision may have a quicker return to function, by 1 year, staged revision has comparable results.

Purpose. To establish the reliability of reporting and recording revision hip and knee arthroplasties by comparing data in the National Joint Registry (NJR), Hospital Episode Statistics (HES) and our local theatre records. Methods. The paper theatre registers for all orthopaedic theatres in the Royal Derby Hospitals NHS Trust were examined for details of revision hip and knee replacements carried out in 2007 and 2008. This was then cross-checked and merged with the local electronic theatre data to obtain a definitive local record of all revision hip and knee arthroplasties. Data for the same period was requested from the NJR and HES and these data were checked against our definitive local record for discrepancies. The HES codes used were the same codes used to compile the recent NJR annual reports. Results. The theatre registers and ORMIS identified 271 revision hip and knee arthroplasties in the study period. The NJR had corresponding data for 176 (65%) of these, and HES had 250 (92%). 10 cases (4%) were not recorded by either NJR or HES: 8 secondary resurfacings of patellae and 2 posterior lip augmentations in hips. Of those operations “missed” by HES, most had been assigned a correct “W” code, but had a “Y” or “Z” OPCS code not used in the NJR annual reports. Conclusion. When HES and the NJR data are combined, they are an accurate representation of real practice. More robust methods of reporting revision arthroplasty to the NJR are required. The OPCS codes used to indicate a revision need to be reviewed

Aims

The outcomes of patients with unexpected positive cultures (UPCs) during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. The objectives of this study were to establish the prevalence and infection-free implant survival in UPCs during presumed aseptic single-stage revision THA and TKA at mid-term follow-up.

Introduction

A proportion of patients with hip and knee prosthetic joint infection (PJI) undergo multiple revisions with the aim of eradicating infection and improving quality of life. The aim of this study was to describe the microbiology cultured from multiply revised hip and knee replacement procedures to guide antimicrobial therapy at the time of surgery.

Aims

The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without.

To ascertain whether there is any relationship between the Oxford 12 scores gained six months post surgery and early revision for primary hip and knee arthroplasty. The six month post surgery Oxford 12 scores were retrieved from the National Joint Registry (NJR) for the seven year period ending 31. st. December 2006. These were analysed in relation to revision of primary hip and knee procedures using three methods of statistical analysis; logistic regression, receiver operating characteristic (ROC) curve and direct plotting of groups of scores against the proportion of hips revised for that same group. Logistic regression: For every one unit increase in the Oxford score there was an 11% increased risk of revision (hips) and 12% (knees) within the first two years of surgery, 5 and 6% respectively between two and four years and 3 and 4% risk respectively between four and six years (p> 0.001). The ROC Curve Analysis: demonstrated that a patient with a score greater than 20 (hips) or 28.5 (knees) or 24 (uni knees) has eight times the risk of needing a revision within two years compared to a person with a score equal or less than the above numbers. Alternatively the ROC analysis predicted 73% of the revisions within three years for all three arthroplasty groups. Plotting Scores Against Revisions: Plotting scores in groups of five demonstrated an incremental increase in the risk during the first two years. A person with a score greater than 40 has; for hips 24 times, knees 27 times and uni knees 69 times the risk of a revision within two years compared to a person with a score between 16 and 20. Monitoring of the six month post surgical Oxford 12 score is another tool in the surgeon’s armamentarium for deciding which patients need closer monitoring following arthroplasty surgery

Abstract

Effective utilisation of blood products is fundamental. The introduction of Maximum Surgical Blood Ordering Schedules (MSBOS) for operations provides guidance for effective cross-matching. A retrospective analysis of blood ordering practices was undertaken to establish an evidence-based MSBOS for revision THR and TKR. The impact of the use of intraoperative cell-salvage devices was also assessed.

Methods: The patient database was searched for cases of revision THR and TKR undertaken over 58 months. These records were then cross-referenced with the transfusion database. The cross-match to transfusion ratios (CTR) and transfusion indexes (TI) were calculated using this data.

The gold standard for the CTR is 2:1 or less. The TI establishes the likelihood of blood being transfused for a certain procedure. If the TI is less than 0.5, then cross-matching blood is considered unnecessary.

Results: For revisions of non-infected THR (n=269), the CTR=2.24 and TI=1.67. In infected cases (n=69), CTR=2.16 and TI=1.68.

In revisions of non-infected TKR (n=95), the CTR=4.33 and TI=0.48. In infected cases (n=54) the CTR=2.16 and TI=1.35.

There was considerable change in the practice of ordering cross-matched blood following the introduction of intraoperative cell-salvage devices (Revision THR: CTR=1.93, TI=0.84; Revision TKR: CTR=1.20, TI=0.16)

Discussion: The analysis confirmed that more blood was requested than was actually required. Overall the results suggest that cross-matching is still necessary for both the non-infected and infected revision THR but the number of units requested could be reduced to 2 units. In revision TKR, transfusions were more likely in infected cases and, a ‘group & save’ may be sufficient for non-infected cases.

The introduction of this MSBOS in conjunction with intraoperative cell-salvage, could promote blood conservation and financial savings.

Introduction: Effective utilisation of blood products is fundamental. The introduction of Maximum Surgical Blood Ordering Schedules (MSBOS) for operations provides guidance for effective cross-matching. A retrospective analysis of blood ordering practices was undertaken to establish an evidence-based MSBOS for revision THR and TKR. The impact of the use of intraoperative cell-salvage devices was also assessed.

Methods: The patient database was searched for cases of revision THR and TKR undertaken over 58months. These records were then cross-referenced with the transfusion database. The cross-match to transfusion ratios (CTR) and transfusion indexes (TI) were calculated using this data.

The gold standard for the CTR is 2:1 or less. Procedures with ratios greater than 3:1 should substitute for a ‘group and save’. The TI establishes the likelihood of blood being transfused for a certain procedure, i.e., the number of units transfused divided by the number of patients having the procedure. If the TI is less than 0.5, then cross-matching blood is considered unnecessary.

Results: For revisions of non-infected THR (n=269), the CTR=2.24 and TI=1.67. In infected cases (n=69), CTR=2.16 and TI=1.68.

In revisions of non-infected TKR (n=95), the CTR=4.33 and TI=0.48. In infected cases (n=54) the CTR=2.16 and TI=1.35.

There was considerable change in the practice of ordering cross-matched blood following the introduction of intraoperative cell-salvage devices (Revision THR: CTR=1.93, TI=0.84; Revision TKR: CTR=1.20, TI=0.16)

Discussion: The analysis confirmed that more blood was requested than was actually required. Overall the results suggest that cross-matching is still necessary for both the non-infected and infected revision THR but the number of units requested could be reduced to 2units. In revision TKR, transfusions were more likely in infected cases and, a ‘group & save’ may be sufficient for non-infected cases.

The introduction of this MSBOS in conjunction with intraoperative cell-salvage, could promote blood conservation and financial savings.

Methicillin Resistant Staphylococcus Aureus (MRSA) screening has reduced rates of MRSA infection in primary total hip (THR) and total knee (TKR) replacements. There are reports of increasing methicillin resistance (MR) in Coagulase Negative Staphylococci (CNS) causing arthroplasty infections. We examined microbiological results of all 2-stage THR/TKR revisions in Tayside from 2001–2010.

72 revisions in 67 patients were included; 30 THRs and 42 TKRs. Mean ages at revision were 89 and 72 years respectively. Male: female ratio 1.4:1.2-year survivorship for all endpoints: 96% in THRs and 88% in TKRs. 5-year survival: 83% and 84% respectively.

The most common organisms were SA (30%) and CNS (29%). Antibiotic resistance was more common amongst CNS. 72% of CNS were resistant to Methicillin versus 20% of SA. 80% of CNS were resistant to Gentamicin OR Methicillin versus 20% of SA. 32% (8/72 cases or 11% overall) of CNS were resistant to BOTH Gentamicin AND Methicillin, the primary arthroplasty antibiotic prophylaxis in our region, versus 4% of SA.

Harris Hip Scores and Knee Society Scores were lower post primary, prior to symptoms of infection in patients who had MR organisms cultured compared with those who had methicillin sensitive organisms. One-year post revision both groups recovered to similar scores.

Our data suggest MR-CNS cause significantly more arthroplasty infections than MRSA. Patients developing MR infections tend to have poorer post-primary knee and hip scores before symptoms of infection fully develop. 32% of CNS causing arthroplasty infections in our region are resistant to current routine primary antibiotic prophylaxis.

Our ongoing aim is to assess the clinical outcome of joint replacement surgery; we wish to contrast the functional outcome of primary and revision patients, and examine what factors may influence this.

Method: Patient data was collected prospectively between Jan 1998 and April 2006. The assessment scores include, the Harris Hip Score, Knee Society Score, SF 36 Health Survey and WOMAC. We compare the pain and function parts of the Knee Society Score for Primary and Revision TKR and the Harris Hip Score for Primary and Revision THR.

Results: The Harris Hip Score improves significantly up to one-year post surgery, with the largest increase occurring at three months. Post surgery improvement then plateaus between one and two years and between two and five years. Revision hip replacement patients display a significant improvement in the Harris Hip Score at three months post surgery, but improvement plateaus after this up to two years. These results are presented graphically.

The Knee Society Score in primary total knee replacement patients improves significantly over time up to one-year post surgery for all components of the score, with the largest increase occurring at three months. Post surgery improvement then plateaus between 1 and 2 years. At 5 years post op both the total score and the function score significantly decrease while there is no change in the knee score component. All components of the Knee Society Score measured in revision knee replacement patients significantly improve at three months post surgery, after which time no further significant improvement is noted.

Discussion: Primary THR patients consistently had higher hip scores than revision patients at all time frames, indicating a better outcome for these patients. When stratified for reason for revision we postulate that a number of well functioning patients are significantly worse following revision surgery. This effect is not seen in the revision TKR group. The decrease in Knee Society Score to five years probably reflects the age of the patients at the time of surgery, which is older than hip replacement patients.

Aim. The prevalence of unexpected positive cultures (UPC) in aseptic revision surgery of the joint with a prior septic revision procedure in the same joint remain unknown. The purpose of this study was to determine the prevalence of UPC in aseptic revisions performed in patients with a previous septic revision in the same joint. As secondary outcome measure, we explore possible risk factors associated with UPC and the re-revision rates. Method. This retrospective single-center study includes all patients between January 2016 and October 2018 with an aseptic revision total hip or knee arthroplasty procedure with a prior septic revision in the same joint. Patients with less than three microbiology samples, without joint aspiration or with aseptic revision surgery performed <3 weeks after a septic revision were excluded. UPC was defined as a single positive culture in a revision that the surgeon had classified as aseptic according to the 2018 International Consensus Meeting. Results. A total of 139 revision total hip/knee arthroplasties in patients with a previous septic revision were performed during the study period. After excluding 47 cases with insufficient information, a total of 92 patients were recruited for final analysis. The patient cohort consist of 52 males and 40 females with a mean age of 70 years (±10.6). There were 66 (71.7%) hips and 26 (28.3%) knees. The mean time between the septic and the aseptic revision was 83 months (±89). The two main causes for the aseptic revision were aseptic loosening (n=57, 62%) followed by instability (n=21, 22.9%). We identified 11 (12%) UPC in the entire cohort, while in 3 cases there was a concordance of the germ compared to the previous septic surgery. There were no differences for the presence of UPC between hips and knees (p=0.282), diabetes (p=0.701), immunosuppression (p= 0.252), previous one-stage or two-stages septic revision (p=0.316), or between the causes for the aseptic revision ((p=0.429). There was no correlation between the UPC and time after the septic revision (p=0.773). Conclusions. The prevalence of UPC in this specific group was similar to those reported in the literature for aseptic revisons. More studies, regarding this patient group are necessitated to better understand and more securely interprete the results in those high-risk aseptic revisions

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

Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration. Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI). 102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA. TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA