Aims. Single-stage revision total knee arthroplasty (rTKA) is gaining popularity in treating chronic periprosthetic joint infections (PJIs). We have introduced this approach to our clinical practice and sought to evaluate rates of reinfection and re-revision, along with predictors of failure of both single- and two-stage rTKA for chronic PJI. Methods. A retrospective comparative cohort study of all rTKAs for chronic PJI between 1 April 2003 and 31 December 2018 was undertaken using prospective databases. Patients with acute infections were excluded; rTKAs were classified as single-stage, stage 1, or stage 2 of two-stage revision. The primary outcome measure was failure to eradicate or recurrent infection. Variables evaluated for failure by regression analysis included age, BMI, American Society of Anesthesiologists grade, infecting organisms, and the presence of a sinus. Patient survivorship was also compared between the groups. Results. A total of 292 consecutive first-time rTKAs for chronic PJI were included: 82 single-stage (28.1%); and 210 two-stage (71.9%) revisions. The mean age was 71 years (27 to 90), with 165 females (57.4%), and a mean BMI of 30.9 kg/m. 2. (20 to 53). Significantly more patients with a known infecting organism were in the single-stage group (93.9% vs 80.47%; p = 0.004). The infecting organism was identified preoperatively in 246 cases (84.2%). At a mean follow-up of 6.3 years (2.0 to 17.6), the failure rate was 6.1% in the single-stage, and 12% in the two-stage groups. All failures occurred within four years of treatment. The presence of a sinus was an independent risk factor for failure (odds ratio (OR) 4.97; 95% confidence interval (CI) 1.593 to 15.505; p = 0.006), as well as age > 80 years (OR 5.962; 95% CI 1.156 to 30.73; p = 0.033). The ten-year patient survivorship rate was 72% in the single-stage group compared with 70.5% in the two-stage group. This difference was not significant (p = 0.517). Conclusion. Single-stage rTKA is an effective strategy with a high success rate comparable to two-stage approach in appropriately selected patients. Cite this article: Bone Joint J 2021;103-B(8):1373–1379

Purpose:. Two-stage revision is the gold standard treatment for chronic periprosthetic infection of the hip or knee. Implantation of a functional antibiotic spacer allows patients the option of two stage revision or living with the spacer in place. Some patients may be satisfied with the activity level that they attain with the functional antibiotic spacer and may avoid the morbidity of a second surgery. Methods:. We retrospectively examined the outcomes of 30 joints in 27 patients treated for chronic periprosthetic infection of the hip or knee at a mean follow-up of 27 months (range 11–46 months). Comparing the patients treated with two-stage revision to those patients living with a functional antibiotic spacer, we used University of California Los Angeles activity scores, modified Harris hip scores, and patient satisfaction measures to answer two main questions: (1) Is there a significant difference in activity level? (2) Is there a significant difference in patient satisfaction? Patient satisfaction was measured on a 1–100 scale with 100 being completely satisfied. Results:. There were no statistically significant differences in the American Society of Anesthesiologists scores between the groups—mean 2.69 in the two-stage group and mean 3.00 in the spacer group (p value 0.255). Statistically significant differences were found between the groups for University of California Los Angeles activity scores—mean 5.3 in the two-stage group and mean 2.8 in the spacer group (p value 0.027). There were no statistically significant differences in modified Harris hip scores—mean 55.6 in the two-stage group and mean 41.6 in the spacer group (p value 0.34). In the subgroup analysis of the modified Harris hip score questions, there was a statistically significant difference in the need for support when ambulating—mean 4.21 in the two-stage group and mean 2.45 in the spacer group (p value 0.024)—and in the distance that can be walked—mean 6.15 in the two-stage group and mean 2.0 in the spacer group (p value 0.005). No statistically significant differences were found in patient satisfaction measures—mean 70.0 in the two-stage group and mean 76.6 in the spacer group (p value 0.65)—though the mean satisfaction measure was higher in the spacer group. Conclusion:. Patients living with a functional antibiotic spacer are less active than patients undergoing a two-stage revision for chronic periprosthetic infection of the hip or knee. Specifically, patients living with a functional antibiotic spacer need more support when ambulating and ambulate shorter distances than patients, who undergo two-stage revision surgery. Despite the decreased activity level, patients living with a functional antibiotic spacer are just as satisfied with the outcome of their joint as those patients treated with a two-stage revision. Patients with modest activity goals may be satisfied to live with a functional antibiotic spacer and to avoid a second surgery

Aims

The management of periprosthetic joint infection (PJI) remains a major challenge in orthopaedic surgery. In this study, we aimed to characterize the local bone microstructure and metabolism in a clinical cohort of patients with chronic PJI.

Aims

Periprosthetic joint infections (PJIs) and osteomyelitis are clinical challenges that are difficult to eradicate. Well-characterized large animal models necessary for testing and validating new treatment strategies for these conditions are lacking. The purpose of this study was to develop a rabbit model of chronic PJI in the distal femur.

Aim. We outline a treatment protocol for subjects with chronic periprosthetic joint infections (PJI) who elected not to have surgery. We developed a method of serial “fluid-depleting” aspirations with intra-articular gentamycin injections to affect the population of the biofilm community. We have experienced many treatment failures, as expected, but have also had a group of subjects who responded exceptionally well, requiring no surgical intervention. Our longest follow-up is 10 years. Method. From June 2009 to December 2018, 372 clinical cases of chronic PJI involving primary and revision TKA and THA were treated. Of these, 25 subjects were treated with an active suppression protocol, in lieu of surgery. The protocol entailed frequent aspirations and intra-articular antibiotic injections to quell the PJI inflammatory response. All aspirations were performed by the treating surgeon in the orthopaedic clinic without fluoroscopic guidance. Based on a subject's response to the protocol, he/she was identified as 1 of 3 classifications: 1) Ongoing Treatment – Biofilm Trained (OTBT), 2) Ongoing Treatment – Biofilm Untrained (OTBU), and 3) Treatment Failure (TF). OTBT subjects showed no clinical signs of infection. Serum biomarkers (CRP, ESR) remained consistently normal and subjects were not on oral suppressive antibiotics. Aspiration analysis and cultures remained negative. Maintenance treatment consisted of a fluid-depleting aspiration with an intra-articular gentamycin injection every 12–16 weeks. OTBU subjects showed improved clinical symptoms, lowered serum biomarkers, and lowered WBC counts, but still demonstrated objective signs of infection. TF subjects did not respond to the protocol and showed unchanged/worsening clinical symptoms. Results. Of the 25 subjects, 8 were THA's and 17 were TKA's. Of these cases, 21 (84%) were endoprosthetic replacements. 8 subjects (32%) were classified as OTBT, 6 (24%) as OTBU, and 11 (44%) as TF. All TF subjects were treated with a two-stage exchange protocol. Conclusions. This study is the first describing the potential of modifying bacterial biofilm in a chronic PJI. While our success rate was modest (32%), “Biofilm Trained” subjects demonstrated dramatic changes. Subjects led normal lives, only minimally disrupted by an aspiration and injection every 3–4 months. In the future, we are looking at different agents to modify the enveloping biofilm, including a pre-aspiration injection of EDTA to disrupt the biofilm surface, followed by injecting benevolent bacteria to transform the biofilm to a benevolent state. If able to achieve such a state in a consistent fashion, the impact on the patient and healthcare communities would be enormous

Aim

Apart from other biomarkers isolated in the synovial fluid, alpha-defensin appears to be a promising diagnostic tool to confirm a periprosthetic joint infection (PJI) in the hip or knee. The purpose of this study was to evaluate the sensitivity and specificity of an alpha defensin lateral flow (ADLF) test compared to usual standard classifications in the diagnostic management of PJI.

Aims

Gram-negative periprosthetic joint infection (PJI) has been poorly studied despite its rapidly increasing incidence. Treatment with one-stage revision using intra-articular (IA) infusion of antibiotics may offer a reasonable alternative with a distinct advantage of providing a means of delivering the drug in high concentrations. Carbapenems are regarded as the last line of defense against severe Gram-negative or polymicrobial infection. This study presents the results of one-stage revision using intra-articular carbapenem infusion for treating Gram-negative PJI, and analyzes the characteristics of bacteria distribution and drug sensitivity.

Background

The purpose of this multi-center, randomized clinical trial was to compare static and articulating spacers in the treatment of PJI complicating total knee arthroplasty TKA.

Aim

Very limited information is available regarding health-related quality of life (HRQOL) and patient reported hip function following treatment for chronic periprosthetic hip joint infection (PJI). Several reviews have not found any clear differences in clinical outcome parameters comparing the most commonly applied treatment strategies for chronic hip PJI. Studies describing patients HRQOL of one-stage and two-stage revision could provide important information regarding patient counselling. The purpose of this study was to investigate HRQOL and patient reported hip function after one-stage revision and two-stage revision in chronic hip PJI.

The management of periprosthetic joint infection is challenging and the duration of systemic antibiotic therapy whether it be during the interval phase or after reimplantation of a new prosthesis is controversial. We report our experience of managing chronic periprosthetic infection of the hip by the two stage exchange procedure. Patients who were scheduled to undergo a two stage revision for chronic periprosthetic infection of the hip were identified from our prospective database. Of 425 patients with microbiologically proven periprosthetic infection, 369 (87%) underwent a two stage procedure, leaving 56 patients who did not proceed to reimplantation. 41 of these were clinically infection free but for personal or medical reasons did not proceed. The remaining 15 had persistent infection. The mean age at the time of the first stage was 68 years (26 – 92 yrs). 256 (61%) patients were alive for review. The mean time between stages was 6.3 months with a mean follow up after the second stage was 65 months (range 5 to 276 months). The success rate of a single 1. st. stage debridement, confirmed by negative cultures at the time of second stage reimplantation was 94%. 19 patients underwent a repeat 1. st. stage debridement and were classed as failures of the 1. st. stage. At the time of final review, 340 (92%) patients were deemed infection free out of those who had completed a 2 stage exchange. The duration of systemic antibiotic treatment after both the 1. st. and 2. nd. stages was divided into <48 hrs and >48 hours. There was no significant difference in the success of the 1. st. stage procedure in patients who received < 48 hours (48% of the patients) as opposed to > 48 hours (p = 0.98, Chi Squared Test, Relative Risk 1.009). Similarly there was no difference in the overall success of the two stage procedure irrespective of the duration of antibiotic therapy with 76% of patients receiving <48hrs of antibiotics after the second stage. Aggressive surgical debridement together with targeted local and short term systemic antibiotic therapy should be the mainstay of treatment in two stage revision surgery

Modern prosthetic stem construction strives to achieve the attractive goals of stress shielding prevention and optimal osteointegration. PhysioLogic stem is a new generation composite isoelastic femoral stem consisting of titanium core sheathed in implantable PEEK polymer and coated with titanium layer. This construction combines the benefits of both stress shielding prevention, due to its elasticity under bending load corresponding closely to that of natural bone, and rapid osteointegration, due to the stem's titanium coating. The aim of this study is long-term clinical progress evaluation and retrospective analysis in patients undergoing primary PhysioLogic stem implantation at our institution. From 1998 to 2003, we performed 51 primary total hip arthroplasty (THA) operations with implantation of PhysioLogic Stem at our institution. Indications for THA included osteoarthritis (21), hip dysplasia (14), rheumatoid arthritis (10), and femoral neck nonunion (6). In all patients we used totally uncemented system — PhysioLogic Stem and monoblock cup with different types of bearing surface articulation (40 metal/polyethylene, 3 ceramic/polyethylene, and 8 metal/metal). In all cases head size was 28mm. Two patients died in the early post-op period at day 1 and day 9 from disseminated intravascular coagulation and pulmonary embolism, respectively, and were excluded from subsequent analysis. Analyzed patients included 20 women and 29 men; median age 45, range 21–69. Post-operatively, the patients were evaluated at 3 and 6 months, 1 year, and yearly thereafter. Median follow-up period was 14 years, range 11 to 16 years. Clinical and functional outcomes were evaluated by Harris Hip Score. Bone density in Gruen's and Charnley's zones was measured by dual-energy x-ray absorptiometry. Four patients died at 5–8 years postoperatively from cardiac causes. Two patients underwent revision surgery: one patient underwent “dry revision” due to hip dislocation with exchange for longer head while keeping the original PhysioLogic stem in place; second patient underwent stem removal after chronic periprosthetic infection. Among the 45 patients with surviving PhysioLogic Stem, 33 patients (75%) underwent subsequent contralateral total hip arthroplasty with standard uncemented stems types Spotorno or Zweymuller. These patients were surveyed at postoperative evaluation about subjective comparative performance of PhysioLogic Stem versus standard stem. Twenty seven patients (82%) reported the PhysioLogic stem to be equivalent or superior to the standard stem, with 15 patients (45%) rating the PhysioLogic stem as subjectively more comfortable than the standard stem. The average Harris hip score improved from 40 points preoperatively (range 27 to 48) to 93 points (range 89 to 95) at the time of final follow-up. All stems continue to show adequate bone-ingrown fixation with no radiological signs of aseptic loosening to date. The PhysioLogic stem removed in the aforementioned case of chronic periprosthetic infection also showed clear signs of good osteointegration. Our study showed that the PhysioLogic stem implantation resulted in favorable clinical and functional performance at long-term follow-up, making it an attractive alternative to standard stems

Traditional mechanical debridement can only remove visibly infected tissue and is unable to completely clear all the biofilm that hides within muscle crevices and nerves. This study aims to determine the results of single-stage revision using noncontact low frequency ultrasonic debridement in treating chronic periprosthetic joint infections (PJI). A prospective study of consecutive patients requiring single-stage revision for chronic PJI was performed since August 2021. After mechanical debridement, an 8‑mm handheld non‑contact low‑frequency ultrasound probe was used for ultrasonic debridement at a frequency of (25±5) kHz and power of 90% for 5 minutes. Each ultrasound lasted 10 seconds with 3‑seconds intervals. The probe was repeatedly sonicated among all soft tissue and bsingle interface. The distal femoral canal and the posterior capsule of the knee were fully sonicated with a special right‑angle probe. Chemical debridement was then performed to irrigation the whole operative area. Recurrence of infection, culture results and number of colonies 24 hours after ultrasonic debridement were recorded. A total of 45 patients (25 hips and 20 knees) were included and 43 of them (95.6%) were free of infection at a mean follow-up time of 29 months (24 to 33). There were no intraoperative complications related to ultrasonic debridement (neurovascular and muscle injury, poor wound healing and fat liquefaction). The culture‑positive rate of wound liquid before ultrasonic debridement was 40.0% (18/45), which significantly increased to 75.6% (34/45) after ultrasonic debridement (P=0.001). The median number of colonies 24 hours after ultrasonic debridement was 2372 CFU/ml (310 to 4340 CFU/ml), which was significantly higher than that before debridement (307 CFU/ml; 10 to 980 CFU/ml) (P=0.000). Single-stage revision with non‑contact low‑frequency ultrasonic debridement can fully expose bacteria within biofilm, increase the efficacy of chemical debridement and lead to a favorable short‑term outcome without related complications

Aims. Accurate diagnosis of chronic periprosthetic joint infection (PJI) presents a significant challenge for hip surgeons. Preoperative diagnosis is not always easy to establish, making the intraoperative decision-making process crucial in deciding between one- and two-stage revision total hip arthroplasty (THA). Calprotectin is a promising point-of-care novel biomarker that has displayed high accuracy in detecting PJI. We aimed to evaluate the utility of intraoperative calprotectin lateral flow immunoassay (LFI) in THA patients with suspected chronic PJI. Methods. The study included 48 THAs in 48 patients with a clinical suspicion of PJI, but who did not meet European Bone and Joint Infection Society (EBJIS) PJI criteria preoperatively, out of 105 patients undergoing revision THA at our institution for possible PJI between November 2020 and December 2022. Intraoperatively, synovial fluid calprotectin was measured with LFI. Cases with calprotectin levels ≥ 50 mg/l were considered infected and treated with two-stage revision THA; in negative cases, one-stage revision was performed. At least five tissue cultures were obtained; the implants removed were sent for sonication. Results. Calprotectin was positive (≥ 50 mg/l) in 27 cases; out of these, 25 had positive tissue cultures and/or sonication. Calprotectin was negative in 21 cases. There was one false negative case, which had positive tissue cultures. Calprotectin showed an area under the curve of 0.917, sensitivity of 96.2%, specificity of 90.9%, positive predictive value of 92.6%, negative predictive value of 95.2%, positive likelihood ratio of 10.6, and negative likelihood ratio of 0.04. Overall, 45/48 patients were correctly diagnosed and treated by our algorithm, which included intraoperative calprotectin measurement. This yielded a 93.8% concordance with postoperatively assessed EBJIS criteria. Conclusion. Calprotectin can be a valuable tool in facilitating the intraoperative decision-making process for cases in which chronic PJI is suspected and diagnosis cannot be established preoperatively. Cite this article: Bone Joint J 2024;106-B(5 Supple B):118–124

Aim. Antibiotics have limited activity in the treatment of multidrug-resistant or chronic biofilm-associated infections, in particular when implants cannot be removed. Lytic bacteriophages can rapidly and selectively kill bacteria, and can be combined with antibiotics. However, clinical experience in patients with surgical infections is limited. We investigated the outcome and safety of local application of bacteriophages in addition to antimicrobial therapy. Method. 8 patients (2 female and 6 male) with complex orthopedic and cardiovascular infections were included, in whom standard treatment was not feasible or impossible. The treatment was performed in agreement with the Article 37 of the Declaration of Helsinki. Commercial or individually prepared bacteriophages were provided by ELIAVA Institute in Tbilisi, Georgia. Bacteriophages were applied during surgery and continued through drains placed during surgery three times per day for the following 5–14 days. Follow-up ranged from 1 to 28 months. Results. Median age was 57 years, range 33–75 years. Two patients were diagnosed with a persistent knee arthrodesis infection, one chronic periprosthetic joint infection (PJI), one cardiovascular implantable electronic device (CIED) infection and four patients with left ventricular assist device (LVAD) infection. The isolated pathogens were multi-drug-resistant Pseudomonas aeruginosa (n=3), methicillin-sensitive Staphylococcus aureus (n=4), methicillin-resistant Staphylococcus aureus (MRSA) (n=1) and methicillin-resistant Staphylococcus epidermidis (MRSE) (n=1). 4 infections were polymicrobial. 5 patients underwent surgical debridement with retention of the implant, 1 patient with PJI underwent the exchange of the prosthesis and one patient with LVAD infection was treated conservatively. All patients received intravenous and oral antibiotic therapy and local application of bacteriophages. At follow-up of 12 month, 5 patients were without signs or symptoms of infection, whereas in one patient with LVAD infection, a relapse was observed with emergence of phage-resistant Pseudomonas aeruginosa. In this patient, no surgical revision was performed. Conclusions. Bacteriophage therapy may represent a valid additional approach, when standard antimicrobial and surgical treatment is not possible or feasible, including in difficult-to-treat infections. In our case series, 5 of 6 patients were infection free after 1 year. Further studies need to address the optimal bacteriophage administration route, concentration, duration of treatment and combination with antimicrobials

Aim. Irrigation and debridement with an irrigation solution are essential components of the surgical management of acute and chronic periprosthetic joint infection (PJI). Nevertheless, there is a lack of agreement regarding the most effective solution to use. The aim of the study was to perform a systematic review and meta-analysis of the current literature concerning the efficacy of different irrigation solutions over bacterial biofilm. Method. This study was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Network meta-analysis (PRISMA-NMA) checklist for systematic reviews and meta-analyses. A comprehensive literature search of PubMed, Cochrane Library, Web of Science and Scopus databases from inception to September 1, 2023. We combined terms related to PJI, biofilm and irrigation solutions studied in vitro. We performed a network meta-analysis to analyze which irrigation solution achieved a higher reduction of colony forming units (CFU) after specific exposure times, always with a maximum of five minutes, replicating intraoperative conditions. Effect-size was summarized with logarithmic response ratio (logRR) and 95% confidence intervals (95% CI). The rank probability for each treatment was calculated using the p-scores. Results. We screened 233 potential sources. Following deduplication, screening and full-text review, four studies with ten irrigation solutions for different duration of exposures were included, always less than five minutes, replicating intraoperative conditions. Solutions were studied over mature biofilms of most frequent bacteria grown over metal, bone cement or polyethylene surfaces. The highest effect was achieved with povidone iodine 10% during 5 minutes (logRR: −12.02; 95% CI: −14.04, −9.99). The best ranked solutions were povidone iodine 10% during five, three and one minute (respective p-scores: 0.977, 0.932, 0.887) and its combination with hydrogen peroxide for 3 minutes (p-score: 0.836). Povidone iodine 0.3% acting for 5 minutes completed the top 5 best ranked solutions in this study (p-score: 0.761). We assumed that there were no inconsistencies in our network because after examining both scenarios, with and without inconsistencies, the results were not significantly different. Conclusions. Our results show that 10% povidone-iodine is the best antiseptic solution when studied in vitro in the context of prosthetic joint infection. However, the included studies did not evaluate the possible cytotoxic effects of these solutions. This should also be taken into account before choosing the most appropriate antiseptic solution

Introduction. Chronic ruptures of the quadriceps tendon after total knee arthroplasty (TKA) are rare but are a devastating complication. The objective of this study was to validate the use of fresh frozen total fresh quadriceps tendon allografts for quadriceps tendon reconstruction. The hypothesis of this work was that the graft was functional in more than 67% of cases, a higher percentage than the results of conventional treatments. Material – methods. We designed a continuous monocentric retrospective study of all patients operated on between 2009 and 2017 for a chronic rupture of the quadriceps tendon after TKA by quadriceps allograft reconstruction. The usual demographic and perioperative data and the rehabilitation protocols followed were collected. Initial and final radiographs were analyzed to measure patellar height variation. The main criterion was the possibility of achieving an active extension of the knee with a quadriceps contraction force greater than or equal to 3/5 or the possibility of lifting the heel off the ground in a sitting position. Results. 29 patients with 33 allografts were included; 3 iterative allografts were performed on ruptures of the initial transplant and 1 patient was grafted on both sides in one step. There were 21 women and 8 men with a mean age of 73 years, and a mean body mass index of 33 kg/m. 2. Ruptures occurred in 22 cases after chronic periprosthetic infection. Walking was allowed immediately in 29 cases, but free mobilization was delayed in 29 cases. Complications affected 22 cases, but the majority of complications were not related to allograft use (including infectious failures and periprosthetic fractures). After a mean follow-up of 52 months, 28 allografts were still in place, and 22 allografts were considered functional. The active quadriceps extension force was rated on average at 3.5/5. The average pre/post-operative patellar height differential was +2 mm. Discussion. This continuous series of 33 allografts is in line with recent publications on the subject. It confirms their negative impact on the functional outcome of the TKA. The complication rate is high but the specific complication rate is not prohibitive. Two thirds of transplants are functional in the long term. Early rehabilitation procedures can be used in these difficult patients with encouraging results. The management of chronic ruptures of the quadriceps tendon after TKA by quadriceps allograft must be part of the current therapeutic options

Aims. To explore the effect of different durations of antibiotics after stage II reimplantation on the prognosis of two-stage revision for chronic periprosthetic joint infection (PJI). Methods. This study involved a retrospective collection of patients who underwent two-stage revision for chronic PJI and continued to use extended antibiotic prophylaxis in two regional medical centres from January 2010 to June 2018. The patients were divided into a short (≤ one month) or a long (> one month) course of treatment based on the duration of antibiotics following stage II reimplantation. The difference in the infection control rate between the two groups was compared, and prognostic factors for recurrence were analyzed. Results. A total of 105 patients with chronic PJI were enrolled: 64 patients in the short course group and 41 patients in the long course group. For 99 of the patients, the infection was under control during a follow-up period of at least 24 months after two-stage revision. For the short course group, the mean duration of antibiotic prophylaxis after stage II reimplantation was 20.17 days (SD 5.30) and the infection control rate was 95.3%; for the long course group these were 45.02 days (SD 15.03) and 92.7%, respectively. There was no significant difference in infection control rates between the two groups (p = 0.676). Cox regression analysis found that methicillin-resistant staphylococcus infection (p = 0.015) was an independent prognostic factor for recurrence. Conclusion. After stage II reimplantation surgery of two-stage revision for chronic PJI, extended antibiotic prophylaxis for less than one month can achieve good infection control rate. Cite this article: Bone Joint Res 2021;10(12):790–796

Introduction. Two-stage revision surgery remains the gold standard as treatment for periprosthetic hip infections. The purpose of this study was to determine the rate of infection eradication after two-stage revision hip arthroplasty in patients treated with intraoperatively surgeon-molded articulating spacers as well as to foreshadow the future economical impact of these articulating antibiotic spacers to those commercially available. Methods. Thirty-five patients who underwent two-stage revision hip arthroplasty due to chronic periprosthetic infection between 2003–2014 were followed clinically and radiographically an average of 4.9 years postoperatively [2.2–9.2]. 17 male and 18 female patients with a mean age of 62 [34–82] had articulating spacers, made in the operating room, inserted at the first stage. [The overall expense of the custom-made antibiotic spacers and the commercially available spacers was calculated and compared using a student t test.]. Results. Thirty-one patients (91%) had no clinical or radiographic signs of infection at the time of most recent follow-up. There were no periprosthetic femur fractures and two (6.0%) had a dislocation of hip spacer prior to the second stage surgery. After reimplantation, three patients (9.0%) suffered dislocations of the prosthetic hip, with one of those patients undergoing a second dislocation of the previously reduced hip. [The antibiotic articulating hip spacer manufactured intraoperatively cost $2,712 as compared to commercially available injectable molds $4,619 (p<0.05) and prefabricated spacers $3,820 (p<0.05).]. Conclusions. Patients treated using intraoperatively molded articulating spacers had similar infection eradication rates and outcomes compared to previously reported commercially available articulating spacers1. In the era of cost containment and surgical bundles, surgeon-made articulating spacers should be considered in the first stage of periprosthetic infections. The adjustment in treatment could equate to a national savings of over $12 million annually

Aim. A growing number of recent investigations on the human genome, gut microbiome, and proteomics suggests that the loss of mucosal barrier function, particularly in the gastrointestinal tract, may substantially affect antigen trafficking, ultimately influencing the close bidirectional interaction between the gut microbiome and the immune system. This cross-talk is highly influential in shaping the host immune system function and ultimately shifting genetic predisposition to clinical outcome. Therefore, we hypothesized that a similar interaction could affect the occurrence of acute and chronic periprosthetic joint infections (PJI). Method. Multiple biomarkers of gut barrier disruption were tested in parallel in plasma samples collected as part of a prospective cohort study of patients undergoing revision arthroplasty for aseptic or PJI (As defined by the 2018 ICM criteria). All blood samples were collected before any antibiotic was administered. Samples were tested for Zonulin, soluble CD14 (sCD14), and lipopolysaccharide (LPS) using commercially available enzyme-linked immunosorbent assays. Statistical analysis consisted of descriptive statistics and ANOVA. Results. A total of 96 patients were consented and included in the study. 32 were classified as PJI (23 chronic and 9 acute), and 64 as aseptic. Both Zonulin and LPS were found to be increased in the acute PJI group 8.448 ± 7.726 ng/mL and 4.106 ± 4.260 u/mL, compared to chronic PJI (p<0.001) and aseptic revisions (p=0.025). sCD14 was found to be increased in both chronic (0.463 ± 0.168 ug/mL) and acute PJI (0.463 ± 0.389 ug/mL) compared to aseptic revisions (p<0.001). Conclusions. This prospective ongoing study reveals a possible link between gut permeability and the ‘gut-immune-joint axis’ in PJI. If this association continues to be born out with larger cohort recruitment, it would have a massive implication in managing patients with PJI. In addition to the administration of antimicrobials, patients with PJI and other orthopedic infections may require gastrointestinal modulators such as pro and prebiotics

Aim. D-dimer is a widely available serum test that detects fibrinolytic activities that occur during infection. Prior studies have explored its utility for diagnosis of chronic periprosthetic joint infections (PJI), but not explored its prognostic value for prediction of subsequent treatment failure. The purpose of this study was to: (1) assess the ability of serum D-dimer and other standard-of-care serum biomarkers to predict failure following reimplantation, and (2) establish a new cutoff value for serum D-dimer for prognostic use prior to reimplantation. Method. This prospective study enrolled 92 patients undergoing reimplantation between April 2015 and March 2019 who had previously undergone total hip/knee resection arthroplasty with placement of an antibiotic spacer for treatment of chronic PJI. Serum D-dimer level, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels were measured preoperatively for all patients. Failure following implantation was defined per the Delphi consensus criteria. Optimal cutoffs for D-dimer, ESR, and CRP were calculated based on ROC curves and compared in their association with failure following reimplantation criteria at minimum 1-year follow-up. Results. 15/92(16.3%) patients failed reimplantation surgery at mean follow up of 2.9 years (range 1.0–4.8). Optimal thresholds for D-Dimer, ESR and CRP were determined to be 1300ng/mL, 30mm/hr, and 1mg/L, respectively. The failure rate in patient with positive D-dimer was significantly higher at 32.0% (8/25) compared to those with negative D-dimer 10.6% (7/66); p=0.024. In comparison, 17.8% (8/45) of patients with ESR above threshold failed, compared to 13.89% (5/41) below (p=0.555) and 16.0% (4/25) of patients with CRP above threshold failed, compared to 16.1% (10/62) below (p=1.000). Conclusions. Patients with elevated D-Dimer appear to be at higher risk of failure after reimplantation surgery. This serum marker may be used to generate an additional data point in patients undergoing reimplantation surgery, especially in circumstances when optimal timing of reimplantation cannot be determined based on clinical circumstances