Aims

Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy.

Deep infection is a devastating complication of total knee arthroplasty (TKA). This study aimed to determine if there was a relationship between surgeon volume and the incidence of revision for infection after primary TKA.

Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 1 September 1999 to 31 December 2020 for primary TKA for osteoarthritis that were revised for infection. Surgeon volume was defined by the number of primary TKA procedures performed by the surgeon in the year the primary TKA was performed and grouped as <25, 25-49, 50-74, 75-99, >100 primary TKA procedures per year. Kaplan Meir estimates for cumulative percent revision (CPR) and Cox Proportional Hazard Ratios were performed to compare rates of revision for infection by surgeon volume, with sub-analyses for patella and polyethylene use, age <65 years and male gender.

5295 of 602,919 primary TKA for osteoarthritis were revised for infection. High volume surgeons (>100 TKA/year) had a significantly lower rate of revision for infection with a CPR at 1 and 17 years of 0.4% (95% CI 0.3, 0.4) and 1.5% (95% CI 1.2, 2.0), respectively, compared with 0.6% (95% CI 0.5, 0.7) and 2.1% (95% CI 1.8, 2.3), respectively, for low volume surgeons (<25 TKR/year). Differences between the high-volume group and the remaining groups remained when sub-analysis for age, gender, ASA, BMI, patella resurfacing and the use of cross-linked polyethylene (XLPE).

High volume surgeons have lower rates of revision for infection in primary TKA.

Aims

The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up.

Aims

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

Introduction and Objective. Evidence in literature is contradicting regarding outcomes of total knee arthroplasty (TKA) in post-traumatic osteoarthritis (PTOA) and whether they are inferior to TKA in primary osteoarthritis (OA). The aim of this review was to find out if any difference exists in the results of TKA between the two indications. Materials and Methods. The electronic databases MEDLINE, EMBASE, The Cochrane Collaboration, and PubMed were searched and screened in duplicate for relevant studies. The selected studies were further subjected to quality assessment using the modified Coleman method. The primary outcome measure was patient reported outcome, and secondary outcome measures were infection, revision, stiffness, and patella tendon rupture. Results. A total of 18 studies involved 1129 patients with a mean age of 60.6 years (range 45.7–69) and follow up of 6.3 years. The time interval from index injury to TKA was 9.1 years. Knee Society Score (KSS) in PTOA reported in 12/18 studies showed functional improvement from 42.5 to 70 post-TKA exceeding minimally clinically important difference. In TKA for primary OA vs PTOA, deep peri-prosthetic joint infection (PJI) was reported in 1.9% vs 5.4% of patients, whilst revision of prosthesis at an average of 6 years post-operatively was performed in 2.6 vs 9.7% of patients. Conclusions. TKA is a successful treatment option for PTOA. However, the risk of significant complications like PJI and implant failure requiring revision is higher than primary OA cases. Patients should be counselled about those risks. Further well-designed comparative cohort-matched studies are needed to compare outcomes between the two populations

Aims

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

Aims. Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. Methods. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. Results. At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. Conclusion. The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129–134

Aims

The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA).

Aims

The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon.

The purpose of this randomized controlled trial is to evaluate the efficacy of using dilute betadine versus sterile saline lavage in aseptic revision total knee (TKA) and hip (THA) arthroplasty to prevent acute postoperative deep periprosthetic joint infection (PJI). Of the 450 patients that were randomized, 5 did not have 90-day follow-up, 9 did not receive the correct treatment, and 4 were excluded for intraoperative findings consistent with PJI. 221 Patients (144 knees and 77 hips) received saline lavage only and 211 (136 knees and 75 hips) received a three-minute dilute betadine lavage (0.35%) prior to wound closure. Patients were observed for the incidence of acute postoperative deep PJI within 90 days of surgery. Statistical analysis was performed using t-tests or Fisher's exact test where appropriate. Power analysis determined that 285 patients per group are needed to detect a reduction in the rate of PJI from 5% to 1% (alpha=0.05, beta=0.20). There were seven PJIs in the saline group and one in the betadine lavage group (3.2% vs. 0.5%, p=0.068). There were no significant differences in any baseline demographics between groups suggesting appropriate randomization. Although we believe the observed difference between treatments is clinically relevant, it was not statistically significant with the sample size enrolled thus far and enrollment is ongoing. Nonetheless, we believe that these data suggests that dilute betadine lavage is a simple method to reduce the rate of acute postoperative PJI in patients undergoing aseptic revision procedures

Deep peri-prosthetic infection after partial or total knee arthroplasty is a disconcerting problem for patient and surgeon alike. The diagnosis of infection is sometimes obvious but frequently requires that the surgeon maintain a substantial index of suspicion for infection as the cause of pain or poor outcome after any joint arthroplasty. While surgical debridement with component retention is appropriate in a subgroup of patients with an acute peri-prosthetic infection, most delayed and chronic infections are best treated with component resection. With carefully selected patients and very aggressive debridement protocols some success has been demonstrated in Europe with single-stage exchange for infection. Most surgeons in North America, however, are unfamiliar with the very aggressive debridement techniques employed at European centers that promote single stage replant; and few surgeons in North America are currently comfortable in cementing a hinged total knee replacement in place for the typical infected TKA nor do they have the patience to re-prep and drape with an entirely new OR setup after debridement and prior to the insertion of the new implant − 2 steps that are often mentioned as important to the success of single stage exchange. The pre-eminent role of two-stage exchange as the definitive treatment was established over 30 years ago. Two-stage exchange remains the gold-standard in treatment with an established track record from multiple centers and with multiple different types of infecting organisms. Some of the historical problems with two-stage exchange, such as limited mobility during the interval stage, have been mitigated with the development of effective articulating spacer techniques. Further, the emergence of drug resistant bacteria and the possibility of fungal infection make two-stage exchange the best choice for the majority of patients with deep periprosthetic joint infection in 2017

Aims

Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in temporary operating theatres. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates.

Background. Around 1% of patients who have hip replacement have deep prosthetic joint infection afterwards. Infection is treated with antibiotics and revision surgery. We aimed to characterise the impact of deep joint infection and its treatment, to identify treatment preferences, and to describe surgeons' treatment decisions. Methods. In a qualitative study in the UK we interviewed 19 patients who had infection after hip replacement and 12 orthopaedic surgeons specialising in infection. Face-to-face interviews with patients explored experience of infection, treatment and recovery. Interviews with surgeons explored treatment decisions. With consent, interviews were audio-recorded, transcribed and anonymised. Once imported into QSR NVivo software, data were analysed using constant comparison. Results. Patients with deep joint infection described mobility loss, pain, loss of valued activities, changes to home environments/moving into care, negative impact on personal relationships and financial strain. Physical and psychological trauma was associated with revision surgery and antibiotic treatment. Patients had strong preferences for treatment options, emphasising impact of surgery, side effects of antibiotics and duration of treatment as key considerations. Although eradication of infection was important, patients felt that reducing impact of treatment was high priority and identified a need for more support. Surgeons' treatment decisions focused on patient characteristics and nature of infection to prioritise eradication of infection. During patients' recovery surgeons' were concerned about possible return of infection and patients' mobility and function. Conclusion. Infection after joint replacement causes physical and psychological trauma. Balancing patients' preferences for reducing impact of treatment with surgeons' emphasis on eradication of infection should be an important consideration in care. There is also need to develop new interventions to support patients with infection. Level of evidence. Level 3 – Qualitative Research. Funding statement. This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1210-12005). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Ethics. This study has been given a favourable opinion for conduct in the NHS by the National Research Ethics Service Committee South West – Exeter 14/SW/0072

Aim. This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture. Method. This study identified a consecutive series of 2,822 (2,052 female, 73%) patients who underwent either hemiarthroplasty (n=1,825, 65%) or fixation (DHS) (n=997, 35%) for fractured neck of femur performed between January 2009 and June 2015 at our institution. Full patient demographics, co-morbidity and peri-operative complication data were determined. The majority of patients were either ASA 2 (n=663, 23%) or ASA 3 (n=1,521, 54%), mean age = 81.3 years (SD 10.3). All patients were followed up post-operatively by a dedicated surgical site infection (SSI) monitoring team in order to identify patients who developed a PJI within 1 year. A stepwise multivariable logistic regression model was used to identify patient and surgical factors associated with increased risk of infection. Predictors with a p-value of <0.20 in the univariate analysis were included in the multivariate analysis. Results. Thirty-nine (39) cases of deep periprosthetic infection were identified (hemiarthroplasty n=35, DHS n=4) representing an overall deep infection rate of 1.4% (hemiarthroplasty 1.9%, DHS 0.4%). The most common infecting pathogen was a pure growth of coagulase negative Staphylococcus (n=9, 23%) followed by a pure growth of Staphylococcus aureus (n=7, 18%). An increased risk of PJI was observed in patients who underwent hemiarthroplasty compared to those treated by fixation (odds ratio (OR) 6.50, 95%CI 2.26 – 18.7, p=0.001). Of patient factors, only blood transfusion within 30 days (OR 3.51, 95%CI 1.72 – 7.13, p=0.001) and the presence or development of pressure sores on or during admission (OR 2.99, 95%CI 1.24 – 7.19, p=0.015) were significantly associated with an increased risk of development of PJI. Use of high-dose dual antibiotic cement (gentamicin and clindamycin) was associated with a two-fold reduction in the risk of PJI (OR 0.39, 95%CI 0.20 – 0.76, p=0.005) vs standard dose gentamicin antibiotic cement. Conclusions. This study found: 1) a deep infection rate similar to that reported earlier from large number studies from the UK, 2) a six-fold higher deep infection rate in hemiarthroplasties, compared to internal fixations, and 3) a three-fold higher infection rate in patients who suffer concomitant pressure sores or receive a blood transfusion up to 30 days post-operatively

Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk.

This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics.

Cite this article: Bone Joint J 2016;98-B:1014–19.

Introduction. The current recommendation by the AAOS in the 2010 clinical practice guidelines for the use of MRI to diagnose a periprosthetic joint infection (PJI) is “inconclusive” given the lack of evidence to support its use. The purpose of this study was to determine the utility of MRI with metal reduction artifact sequencing in diagnosing a periprosthetic joint infection (PJI) after total hip arthroplasty (THA). Methods. 176 patients who underwent MRI with multi-acquisition variable resonance image combination (MAVRIC) to reduce metal artifact for a painful THA between the years of 2009–2013 were retrospectively evaluated. All MRIs were read by one of four radiologists with extensive experience in interpreting MRIs after THA. All MRIs were performed using a 1.5 Tesla magnet. Of the 176 patients examined, 16 patients were found to have a deep periprosthetic joint infection using Musculoskeletal Infection Society (MSIS) criteria after the MRI was performed. MRI reads were classified as either positive (read as “evidence of active infection” or “suspicious for infection”) or negative (read as no evidence of infection). Only one patient who had a positive MRI read was excluded because of loss to followup after the MRI was performed. Results. Of the 160 aseptic patients, only one patient was read as suspicious for infection (false positive rate = 0.6%, specificity=99.4%, negative predictive value (NPV)=98.8%). Of the 16 patients with an infected THA, 14 patients were read as positive for infection (false negative rate=12.5%, sensitivity = 87.5%, positive predictive value (PPV)=93%). Conclusion. MRI with metal reduction artifact sequence is a highly specific test to diagnose or rule out a PJI with a low false positive rate and excellent PPV and NPV however, given its lower sensitivity than published for the serum C-reactive protein, is not recommended as a general “screening” test for all patients with pain after THA to rule out infection

Introduction. The current recommendation by the AAOS in the 2010 clinical practice guidelines for the use of MRI to diagnose a periprosthetic joint infection (PJI) is “inconclusive” given the lack of evidence to support its use. The purpose of this study was to determine the utility of MRI with metal reduction artifact sequencing in diagnosing a periprosthetic joint infection (PJI) after total hip arthroplasty (THA). Methods. 176 patients who underwent MRI with multi-acquisition variable resonance image combination (MAVRIC) to reduce metal artifact for a painful THA between the years of 2009–2013 were retrospectively evaluated. All MRIs were read by one of four radiologists with extensive experience in interpreting MRIs after THA. All MRIs were performed using a 1.5 Tesla magnet. Of the 176 patients examined, 16 patients were found to have a deep periprosthetic joint infection using Musculoskeletal Infection Society (MSIS) criteria after the MRI was performed. MRI reads were classified as either positive (read as “evidence of active infection” or “suspicious for infection”) or negative (read as no evidence of infection). Only one patient who had a positive MRI read was excluded because of loss to followup after the MRI was performed. Results. Of the 160 aseptic patients, only one patient was read as suspicious for infection (false positive rate = 0.6%, specificity=99.4%, negative predictive value (NPV)=98.8%). Of the 16 patients with an infected THA, 14 patients were read as positive for infection (false negative rate=12.5%, sensitivity = 87.5%, positive predictive value (PPV)=93%). Conclusion. MRI with metal reduction artifact sequence is a highly specific test to diagnose or rule out a PJI with a low false positive rate and excellent PPV and NPV however, given its lower sensitivity than published for the serum C-reactive protein, is not recommended as a general “screening” test for all patients with pain after THA to rule out infection

Deep periprosthetic infection after hip or knee arthroplasty is a disconcerting problem for patient and surgeon alike. The diagnosis of infection is sometimes obvious but frequently requires that the surgeon maintain a substantial index of suspicion for infection as the cause of pain or poor outcome after any joint arthroplasty. While surgical debridement with component retention is appropriate in a subgroup of patients with an acute periprosthetic infection most delayed and chronic infections are best treated with component resection. The pre-eminent role of two-stage exchange as the definitive treatment was established over 30 years ago. Two-stage exchange remains the gold-standard in treatment with an established track record from multiple centers and with multiple different types of infecting organisms. Some of the historical problems with two-stage exchange, such as limited mobility during the interval stage, have been mitigated with the development of effective articulating spacer techniques. Further, the emergence of drug resistant bacteria and the possibility of fungal infection make two-stage exchange the best choice for the majority of patients with deep periprosthetic joint infection in 2015

The common recommended treatment for infected total hip replacement is two-staged exchange including removal of all components. However, removal of well-fixed femoral stems can result in structural bone damage. We recently reported on an alternative treatment of partial two-stage exchange used in selected cases, in which a well-fixed femoral stem was left and only the acetabular component removed, the joint space was debrided thoroughly, an antibiotic-laden polymethylmethacrylate spacer was moulded using a bulb-type syringe and placed in the acetabulum, intravenous antibiotics were administered during the interval, and delayed re-implantation was performed. In 19 patients treated with this technique from January 2000 to January 2011, 89% were free of infection at a mean follow-up of four years (2 to 11). Since then, disposable silicone moulds have become available to fabricate spacers in separate femoral and head units. The head spacer mould, which incorporates various neck taper adapter options, greatly facilitates the technique of partial two-stage exchange. We report our early experience using disposable silicone head spacer moulds for partial two-stage exchange in seven patients with infected primary hip replacements.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):66–9