Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes.

Cite this article: Bone Joint J 2024;106-B(12):1377–1384.

Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

Periprosthetic joint infection (PJI) remains an extremely challenging complication. We have focused on this issue more over the last decade than previously, but there are still many unanswered questions. We now have a workable definition that everyone should align to, but we need to continue to focus on identifying the organisms involved. Surgical strategies are evolving and care is becoming more patient-centred. There are some good studies under way. There are, however, still numerous problems to resolve, and the challenge of PJI remains a major one for the orthopaedic community. This annotation provides some up-to-date thoughts about where we are, and the way forward. There is still scope for plenty of research in this area.

Cite this article: Bone Joint J 2022;104-B(11):1193–1195.

Periprosthetic joint infection (PJI) is a difficult complication requiring a comprehensive eradication protocol. Cure rates have essentially stalled in the last two decades, using methods of antimicrobial cement joint spacers and parenteral antimicrobial agents. Functional spacers with higher-dose antimicrobial-loaded cement and antimicrobial-loaded calcium sulphate beads have emphasized local antimicrobial delivery on the premise that high-dose local antimicrobial delivery will enhance eradication. However, with increasing antimicrobial pressures, microbiota have responded with adaptive mechanisms beyond traditional antimicrobial resistance genes. In this review we describe adaptive resistance mechanisms that are relevant to the treatment of PJI. Some mechanisms are well known, but others are new. The objective of this review is to inform clinicians of the known adaptive resistance mechanisms of microbes relevant to PJI. We also discuss the implications of these adaptive mechanisms in the future treatment of PJI.

Cite this article: Bone Joint J 2022;104-B(5):575–580.

Aims

The outcome of repeat septic revision after a failed one-stage exchange for periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat septic revision after a failed one-stage exchange, and to determine whether the Musculoskeletal Infection Society (MSIS) stage is associated with subsequent infection-related failure.

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Septic arthritis of the hip often leads to irreversible osteoarthritis (OA) and the requirement for total hip arthroplasty (THA). The aim of this study was to report the mid-term risk of any infection, periprosthetic joint infection (PJI), aseptic revision, and reoperation in patients with a past history of septic arthritis who underwent THA, compared with a control group of patients who underwent THA for OA.

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One-stage exchange for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) is gaining popularity. The outcome for a repeat one-stage revision THA after a failed one-stage exchange for infection remains unknown. The aim of this study was to report the infection-free and all-cause revision-free survival of repeat one-stage exchange, and to investigate the association between the Musculoskeletal Infection Society (MSIS) staging system and further infection-related failure.

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Fungal and mycobacterial periprosthetic joint infections (PJI) are rare events. Clinicians are wary of missing these diagnoses, often leading to the routine ordering of fungal and mycobacterial cultures on periprosthetic specimens. Our goal was to examine the utility of these cultures and explore a modern bacterial culture technique using bacterial blood culture bottles (BCBs) as an alternative.

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Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Two-stage revision has traditionally been considered the gold standard of treatment for established infection, but increasing evidence is emerging in support of one-stage exchange for selected patients. The objective of this study was to determine the outcomes of single-stage revision TKA for PJI, with mid-term follow-up.

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Failure of irrigation and debridement (I&D) for prosthetic joint infection (PJI) is influenced by numerous host, surgical, and pathogen-related factors. We aimed to develop and validate a practical, easy-to-use tool based on machine learning that may accurately predict outcome following I&D surgery taking into account the influence of numerous factors.

Aim. The use of piperacillin/tazobactam with vancomycin as empirical antimicrobial therapy (EAT) for prosthetic joint infection (PJI) has been associated with an increased risk of acute kidney injury (AKI), leading to propose cefepim as an alternative since 2017 in our reference center. The present study compared microbiological efficacy and tolerance of these two EAT strategies. Method. All patients with PJI empirically treated by vancomycin-cefepim (n=90) were prospectively enrolled in an observational study, and compared with vancomycin-piperacillin/tazobactam-treated historical controls (n=117), regarding: i) the proportion efficacious empirical regimen (i.e., at least one of the two molecules active against the identified organism(s) based on in vitro susceptibility testing); and ii) the incidence of empirical therapy-related adverse events (AE), classified according to the Common terminology criteria for AE (CTCAE). Results. Among the 146 (67.3%) documented infections, the EAT was considered as efficacious in 99 (99.0%) and 66 (98.5%) in the piperacillin-tazobactam and cefepim-treated patients, respectively (p=0.109). The rate of adverse events, and in particular AKI, was significantly higher in the vancomycin-piperacillin/tazobactam (n=38 [32.5%] and 32 [27.6%]) compared to the vancomycin-cefepim (n=13 [14.4%] and 5 [5.7%]) group (p=0.003 and <0.001, respectively). Of note, sex, age, and the proportion of patients receiving other nephrotoxics were similar among piperacillin/tazobactam- and cefepim-treated patients. However, in comparison with patients receiving cefepim, a higher modified Charlson's comorbitidy index (4 [IQR, 3–5] versus 2 [IQR, 2–4], p<0.001) has to be acknowledged, mainly related to a higher prevalence of baseline chronic renal injury (n=62, 53.4% versus n=34, 38.6%; p=0.035). Conclusions. The empirical use of vancomycin-cefepim in PJI was as efficient as vancomycin-piperacillin/tazobactam, and was associated with a significantly lower incidence of AKI

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. Methods. We performed a systematic review of randomized control trials, cohort studies, and case series through May 2019, searching Embase, Medline via PubMed, and Cochrane Library for the concept of two-stage reimplantation for the treatment of hip and knee PJIs, yielding 464 unique citations for abstract review, of which 135 were reviewed in full. Our parameters of interest included: reinfection and mortality events following successful reimplantation, the timing of these events, and the microbiology of index and recurrent infections. Results. Meeting our criteria were 59 studies with 4,494 patients (1,842 hips) who had completed reimplantation. Among successfully reimplanted hips, 4.76% (95% CI, 2.00–8.41) were reinfected by 24 months, 6.84% (4.92–9.02) were reinfected by final follow-up, 1.6% (0.32–3.52) were reinfected with an identical organism(s) with identical resistance, and 2.55% (0.77–5.03) were reinfected with a novel organism(s) or novel resistance. In 24 studies with reinfected patients and sufficient data, 8 studies reported an average interval from reimplantation to reinfection greater than 24 months, and 14 reported at least 1 patient with a reinfection event greater than 48 months following reimplantation. Conclusion. The results from this review determined that the host of an index PJI faces ongoing risk of recurrent infection years into the post-operative period despite initial eradication and that novel microbiology is the cause of a significant proportion of failures. For any tables or figures, please contact the authors directly

Aims

The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI).

Introduction. Despite recent advances in the diagnosis of periprosthetic joint infection(PJI), identifying the infecting organism continues to be a challenge, with up to a third of PJIs reported to have negative cultures. Current molecular techniques have thus far been unable to replace culture as the gold standard for isolation of the infecting pathogen. Next- generation sequencing(NGS) is a well-established technique for comprehensively sequencing the entire pathogen DNA in a given sample 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 PJI. Methods. After obtaining Institutional Review Board approval and informed consent for all study participants, samples were prospectively collected from 148 revision total joint arthroplasty procedures (83 knees, 65 hips). Synovial fluid, deep tissue and swabs were obtained at the time of surgery and shipped to the laboratory for NGS analysis (MicroGenDx). Deep tissue specimens were also sent to the institutional laboratory(Thomas Jefferson University Hospital) for culture. PJI was diagnosed using the Musculoskeletal Infection Society(MSIS) definition of PJI. Statistical analysis was performed using SPSS software. Results. Fifty-five revisions were considered infected; culture was positive in 40 of these (40/55, 72.7%), while NGS was positive in 47 (47/55, 85.5%). Among the positive cultures, complete concordance between NGS and culture was observed in 33 cases (33/40, 82.5%). One case was partially discordant between NGS and culture, with culture detecting three organisms as opposed to one organism on NGS. One case showed complete discordance with NGS and culture detecting different organisms. Three patients with negative NGS results had positive cultures. In another two cases culture simply reported the gross morphology of the organism but the phenotype was not identified, while NGS was able to definitively identify an organism. Among the 15 cases of culture-negative PJI, NGS was able to identify an organism in 10 cases (10/15, 66.7%). These data are summarized in Figure 1. Ninety-three revisions were considered to be aseptic; NGS exclusively identified microbes in 15 of 93 “aseptic” revisions (16.1%) and culture exclusively isolated an organism in 4 of 93 cases(5.3%). One case was positive on both NGS and culture, however the results were discordant from each other. The remaining cases (73/93, 78.5%) 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 (6.8 vs. 4.0, respectively). Discussion. NGS was able to detect a pathogen in two-thirds of culture-negative cases and demonstrated a high rate of concordance with culture in culture-positive cases. The rate of false positives was low compared to earlier studies using molecular techniques. Our findings also suggest that some cases of PJI may be polymicrobial and escape detection using conventional culture. NGS may be a useful adjunct for identifying the causative organism(s) in PJI, particularly in the setting of negative cultures. Further study is required to determine the significance of isolated organisms in samples from patients who are not thought to be infected

Aims

Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure.

The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a suboptimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. For most patients, antibiotics alone are not an acceptable method of treatment, and surgery is necessary. The standard of care for established infection is two stage revision with antibiotic loaded cement during the interval period and parental antibiotic therapy for six weeks. Single stage revision may have economic and functional advantages, however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors. Our protocol has included single stage revision using antibiotic loaded cement in both THA and TKA. This was only undertaken when sensitive organisms were identified pre-operatively by aspiration and appropriate antibiotics were available to use in cement. Patients with immunocompromise, multiple infecting organisms or recurrent infection were excluded. Patients with extensive bone loss that required allograft reconstruction or where a cementless femoral component was necessary were also excluded. Our algorithm was validated first in the hip and extended to infected TKA in 2004. This protocol has now been applied in over 100 TKA revisions for infection between 2004 and 2009. Our single stage revision rate is now over 25%. We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two stage revision cases. Whilst our indications are arbitrary and not based on specific biomarkers, we present excellent results for selective single stage exchange. A minimum three year follow-up suggests that these patients have shorter hospital stays, higher satisfaction rates and better knee scores. An ongoing evaluation is in place. One stage revision arthroplasty for infection offers potential clinical and economic advantages in selected patients

The infected joint arthroplasty continues to be a very challenging problem. Its management remains expensive, and places an increasing burden on health care systems. It also leads to a long and difficult course for the patient, and frequently a suboptimal functional outcome. The choice of a particular treatment program will be influenced by a number of factors. These include the acuteness or chronicity of the infection; the infecting organism(s), its antibiotic sensitivity profile and its ability to manufacture glycocalyx; the health of the patient; the fixation of the prosthesis; the available bone stock; and the particular philosophy and training of the surgeon. Although there have been multiple developments to enhance our ability to effect two-stage techniques whilst limiting inpatient stay, cost and patient morbidity - these include functional spacers, the use of local as well as systemic antibiotics, and home intravenous therapy programmes – there is nevertheless still a considerable morbidity and mortality to the two-stage process, and a massive cost to the patient who has to have two operations with an unpredictable interval period in between and to the local tissues which have already been damaged and are violated on two occasions. The push for one-stage surgery has generally been from centers who are passionate about that technique and has involved a combination of knowing the organism in question prior to surgery, a very radical debridement, the use of hinge / tumor-type implants and prolonged antibiotic therapy post-surgery. The last decade has seen an evolution whereby we have recognised that treatment may be tailored to the patient. There is a big difference between a relatively healthy host and someone with multiple comorbidities, and a big difference between infection with a relatively benign organism and polymicrobial infection with multi-resistant bacteria or fungi. There has, therefore, been increased interest in the use of single-stage revision in order to decrease morbidity, potentially decrease mortality and to decrease cost to the health care system. Single stage revision may have economic and functional advantages, however. We have devised a protocol that dictates the type of revision to be undertaken based on host, organism and local factors. Whilst we believe that there is a role for both single- and two-stage techniques in our armamentarium, we have gradually evolved to increasing use of single-stage surgery. We use antibiotic-loaded cement whenever possible but can reconstruct most cases using semiconstrained implants without resorting to a hinge. We continue to see a lower reinfection rate in these carefully selected patients, with high rates of infection control and satisfaction and better functional and quality of life scores than our two-stage revision cases. We use hinge reconstruction in less than 20% of cases

Aims

The aim of this study was to establish the diagnostic accuracy of culture of joint aspirate with and without saline injection-reaspiration.

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

Periprosthetic joint infection (PJI) remains a challenging complication following Total Hip Arthroplasty (THA). It is associated with high levels of morbidity, mortality and is time consuming and expensive to treat. Our management generally relies on identification of the infecting organism(s) in order to define the appropriate treatment strategy. Patients with culture-negative PJI poses a greater challenge to surgeons and to the wider multidisciplinary team. This study compares the outcomes of 50 consecutive complex culture-positive (deemed unsuitable for single stage exchange) and 50 culture-negative THAs managed with two-stage revision arthroplasty with a minimum of five years follow-up. Culture-negative PJIs were associated with older age, smoking, external referral source and greater use of preoperative antibiotics. There was however no significant difference in outcome between these groups of patients with a similar complication rates and reinfection rates of 6% at 5 years. Culture negative periprosthetic sepsis generates concern, and is often considered a poor prognostic indicator. This study suggests that a strict 2 stage protocol is associated with satisfactory outcomes in such cases