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. Patients and methods. A total of 1223 primary hip and knee arthroplasties were performed between August 2012 and June 2013. A total of 539 (44%) were performed in temporary theatres. The two groups were matched for age, gender, body mass index and American Society of Anesthesiologists grade. Results. The deep infection rate for standard operating theatres was 0 of 684 (0%); for temporary theatres it was eight of 539 (1.5%) (p = 0.001). Conclusion. Use of a temporary operating theatre for primary hip and knee arthroplasty was associated with an unacceptable increase in deep infection. We do not advocate the use of these theatres for primary joint arthroplasty. Cite this article: Bone Joint J 2017;99-B:917–20

Infection following total hip or knee arthroplasty is a serious complication. We noted an increase in post-operative infection in cases carried out in a temporary operating theatre. We therefore compared those cases performed in standard and temporary operating theatres and examined the deep periprosthetic infection rates. A total of 1233 primary hip and knee arthroplasties were performed between August 2012 and June 2013. 44% were performed in temporary theatres. The two groups were matched for age, sex, BMI and ASA grade. The deep infection rate for standard operating theatres was 0/684 (0%); for temporary theatres it was 8/539 (1.5%); p=0.001. Use of a temporary operating theatre for primary hip and knee arthroplasty was associated with an unacceptable increase in deep infection. We do not advocate the use of these theatres for primary joint arthroplasty

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 number of revision total knee arthroplasties (TKA) that are performed is expected to increase. However, previous reports of the causes of failure after TKA are limited in that they report the causes at specific institutions, which are often dependent on referral patterns. Our aim was to report the most common indications for re-operations and revisions in a large series of posterior-stabilised TKAs undertaken at a single institution, excluding referrals from elsewhere, which may bias the causes of failure.

Endoprosthetic replacement following oncological conditions has shown to be at higher risk of sceptical complications due to the use of implants of unusual size, major soft tissue loss and immunsupression. 373 patients have been treated at our institution for malignant tumours of the bone or soft tissue around the knee with a modular tumour-prostheses of the knee joint since their availability from 1978. Infection or septic complications were identified in 78 patients (20.9%). In 15 cases of superficial wound healing disturbances with a fistula simple excision and revision of the wound was performed. In 48 cases of deep periprosthetic infections patients underwent one-stage revision with explantation of the total prosthetic material except femoral and tibial stems, extensive debridement of the wound and replantation of the disinfected prostheses throughout one operation. In 8 patients two-stage revision of the prostheses was performed, using an antibiotic impregnated cement spacer and Steinmann nails. In 5 patients amputation of the affected limb was indicated, whereas 2 patients could be treated conservatively. Out of the patients treated by one-stage revision 16 developed recurrent infection and had to undergo consecutive surgery. After two-stage surgery 4 patients showed signs of septic recurrence. According to our results deep periprosthetic infection of tumour-prostheses primarily can be treated by one-stage revision, in recurrent infections, however, two-stage revision should be performed. We additionally suggest the use of local or pedicled muscle flaps to obtain better soft tissue coverage of the prostheses after 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

Persistent wound drainage after total joint arthroplasty (TJA) has been associated with a higher incidence of superficial and deep periprosthetic infection but the predictors for prolonged drainage and its outcome have not been thoroughly studied. A consecutive series of 7,153 TJA cases performed between 2000 and 2006 at our institute, were recruited into this study. There were 301 cases (4.2%) of persistent wound drainage, defined as discharge from the wound for > 48 hours. The cases were matched in a 2:1 ratio for type of surgery, joint replaced, and date of surgery. This study identified higher BMI (p< 0.005), malnutrition as defined by serum albumin< 3.4g/dl (p< 0.04), longer operative time (p< 0.01), and higher medical comorbidities, in particular diabetes (p< 0.001) as important risk factors for persistent wound drainage. In addition, patients in the drainage group were more likely to have a peak INR of > 1.5 (p< 0.001) during their hospital stay. Patients with wound drainage had a significantly lower hemoglobin postoperatively (p< 0.01) that necessitated greater number of postoperative allogenic transfusions (p=0.004). The hospital length of stay for the drainage group was also significantly higher (p< 0.005). One of the major risk factors for development of deep infection was prolonged drainage (> 7 days). In the deep hematoma and periprosthetic subgroups, the mean of delay in treatment was 6 days in those with retention of the prosthesis and successful outcome, and 9.5 days for those with failure of incision and drainage leading to resection arthroplasty (p= 0.03). 72% of the patient were successfully treated by oral or intravenous antibiotics. 27% required at least one re-operation for deep hematoma and 13% developed deep periprosthetic infection, resulting in 6% rate of resection arthroplasty. 1.5% of those with drainage remained in girdlestone status. This study suggests early surgery for persistent drainage and avoidance of aggressive anticoagulation

Aim: To determine the cost of medical treatment of infection following total joint replacement (TJR) of the hip or knee. With this information, and obtaining the current costs of antibiotics, antibiotic loaded cement and laminar flow theatres, we aimed to calculate the relative cost- benefit of these prophylactic strategies to prevent infection. Method: Fifty two patients who were admitted to The Canberra Hospital (TCH) for treatment of infection at following total joint arthroplasty between January 1996 and January 2001. A detailed cost analysis of treatment costs following infection was performed. All ward, theatre, prosthesis, investigation, pharmaceutical, allied health and medical costs were collated to produce a total cost of treatment. Current costs of prophylactic antibiotics, antibiotic cement and laminar flow theatres were obtained from suppliers. Costs were calculated for different combinations of prophylactic measures using the rates of deep periprosthetic infection reported through the Swedish Arthroplasty Registry. Results: There were 41 deep infections and 13 superficial. The average cost for the 54 patients for the in hospital treatment of infection was $41,215. The cost of treating a superficial infection with antibiotics alone averaged $17,663. The average cost of a two stage revision procedure for deep periprosthetic infection was $79,623. Assuming a hospital volume of 150 cases per year, the use of prophylactic intravenous antibiotics, the use of laminar flow and the combined use of antibiotics and laminar flow were significantly cost effective. The addition of antibiotic loaded cement was marginally cost ineffective in combination with either or both of intravenous antibiotics or laminar flow. Conclusion: The in hospital costs for the treatment of infection after TJR in the Australian setting have been addressed for the first time. Past studies have underestimated the cost of treatment. With this information, we have shown that the combinations of laminar flow and intravenous antibiotic for prophylaxis against infection in TJR are justified on a purely financial cost benefit basis

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

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 use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses. Patients and Methods. All patients who had a noninvasive growing endoprosthesis inserted at the time of a revision procedure were identified from our database. A total of 21 patients (seven female patients, 14 male) with a mean age of 20.4 years (10 to 41) at the time of revision were included. The indications for revision were mechanical failure, trauma or infection with a residual leg-length discrepancy. The mean follow-up was 70 months (17 to 128). The mean shortening prior to revision was 44 mm (10 to 100). Lengthening was performed in all but one patient with a mean lengthening of 51 mm (5 to 140). Results. The mean residual leg length discrepancy at final follow-up of 15 mm (1 to 35). Two patients developed a deep periprosthetic infection, of whom one required amputation to eradicate the infection; the other required two-stage revision. Implant survival according to Henderson criteria was 86% at two years and 72% at five years. When considering revision for any cause (including revision of the growing prosthesis to a non-growing prosthesis), revision-free implant survival was 75% at two years, but reduced to 55% at five years. Conclusion. Our experience indicates that revision surgery using a noninvasive growing endoprosthesis is a successful option for improving leg length discrepancy and should be considered in patients with significant leg-length discrepancy requiring a revision procedure. Cite this article: Bone Joint J 2018;100-B:370–7

Propionibacteria are organisms of low virulence, although they do cause deep periprosthetic infections. The aim of this study was to show that Propionibacteria do not always cause a significant rise in ESR and CRP. Between May 2001 and May 2004, we identified 77 patients with prosthetic joint replacements colonised with Propionibacteria, 47 males and 30 females. There were 47 hip joint replacements, 27 knee joint replacements, 2 endoprosthetic replacements of the femur and 1 shoulder joint replacement. We retrieved successfully the medical records of 66 patients in order to identify the number of patients treated for an infected prosthetic joint arthroplasty. The pre-operative values of ESR and CRP were recorded. For the purposes of this study, an ESR rate of 30mm/hr or higher and a CRP level of 10mg/lt or higher were considered to be suggestive of infection and were deemed a positive result. All of the 77 patients had both ESR and CRP measured pre-operatively. In only 16 (21%) both ESR and CRP were higher than 30mm/hr and 10mg/l respectively. In 33 patients (43%) with prosthetic joint replacements colonised with Propionibacteria, the pre-operative values of ESR and CRP were normal. 23 patients were treated for an infected prosthetic joint arthroplasty. In 7 (30%) of those patients both ESR and CRP were normal. This suggests that normal pre-operative values of ESR and CRP in suspected failed prosthetic joint replacements might not exclude infection, if the causative organism is of low virulence such as Propionibacteria

The risk factors associated with 34 deep infections from a consecutive series of 803 total hip replacements have been analysed using standard actuarial methods. The follow-up ranged from 3 to 10 years. Absence of prophylactic antibiotics, complications after operation, discharging wounds, previous operations and remote infection were related to the development of deep periprosthetic infection. An early discharge from the wound with growth of micro-organisms, though superficial in appearance, proved to be associated with a high risk of developing late deep infection. The mechanisms associated with deep infection involved multiple interrelated risk factors. Multiple regression analysis of our data indicated that these risk factors, when acting together, potentiate their effect on the development of the deep infection

Introduction and purpose: Two-stage reimplantation of a hip replacement is the treatment of choice for deep periprosthetic infections. The purpose of this study is to analyse the survival of the femoral component in two-stage hip replacement reimplantations and compare the results of cemented and cementless components. Materials and methods: Between 1988 and 1998 our hospital carried out 169 two-stage reimplantations for treatment of first episodes of deep infection. The femoral component was cemented in 121 cases and cementless in 48. All patients were followed up clinically and radiologically for at least five years. Results: The two-stage revision was associated with a significant clinical improvement. The reinfection rate was 9% (16/169), of which 11 patients underwent revision surgery and five received chronic suppressive antibiotic treatment. Eight patients required revision due to aseptic loosening and two for periprosthetic fracture. With the numbers available, fixation with or without cement showed no significant differences. Conclusions: The two-stage revision of an infected hip prosthesis resolved the infection in 91% of the cases. An additional 5% required revision due to aseptic loosening. The surgical outcomes seem to be independent of the femoral component fixation (cemented or cementless)

An analysis on prospective data collected on our hip database was carried out on all patients undergoing primary cemented unilateral total hip arthroplasty in the last 5 years comparing the short term outcomes between diabetics and non-diabetics. There were 1220 non-diabetics and 77 diabetics identified from the database with at least 3 years follow up. (average 3.6 years). We found no significant difference with respect to age, sex and diagnosis between the 2 groups. Diabetics did have a significantly higher BMI (30.2 versus 27.7, p< 0.001) and higher incidence of coronary artery disease (31% versus 15%, p< 0.001) We found no increase in the rate of deep periprosthetic infection, superficial wound complications, dislocation, blood loss and DVT between diabetics and non-diabetics even after adjusting for potential confounders of age, sex, diagnosis, BMI and the presence of coronary artery disease. The only factor that was found to be significantly different between the 2 groups was length of stay (10.73 versus 9.56 days, p< 0.05). Further analysis of the diabetic group only showed no difference with regard the same outcomes between insulin-dependent, diet-controlled and diet and oral hypoglycaemic-controlled patient subsets. From this study we conclude that at the time of taking informed consent from diabetic patients undergoing total hip arthroplasty the only potential difference from non-diabetics is that the length of stay may be longer

Problem: Deep infection after hip- or knee-replacement is a severe complication that may lead to implant removal or arthrodesis. Aim: In our hospital intraoperativ subcoutanues culture samples were taken before wound closure. We wanted to know if positive cultures are of any predicitive value in relation to early or late periprosthetic infection. If so, is there a consequence in treatment ? Also costs were analysed. Material and methods: In 2002 we performed 167 primary hip and knee replacements. We retrospectivaly analysed the outcome of 159 cases over a follow-up period of up to 28 month. Results: In 96.8% of the cases a culture sample was taken. Of these 5.8% showed germ growth. In only 4 cases positive cultures were followed by a change in treatment, either antibiotics or revision. Of nine patients with revision surgery only one had a positive culture. Four cases showed germ growth during revision surgery after sterile cultures during implantation. Most often different bacterias were found in primary and revision surgery. In 1.25% deep periprosthetic infection occured. One required second stage knee-replacement, one case ended in resection arthroplasty. Conclusion: Intraoperative culture sample is of no predictive value in primary joint replacement. There is no correlation between positiv cultures and indication for revision surgery. However costs for culture analysis and antibiotics are low compared to the increase of expense caused by periprosthetic infections

Bacteriophage state currently an attractive alternative for antibiotics, especially due to the strong in vitro activity and lack of side effects. Eight patients with chronic infection in musculoskeletal system.are presented. This group includes: 3 cases of deep periprosthetic infection, posttraumatic osteomyelitis of tibia in 2 cases, infected pseudoarthrosis of femur in 1 case, chronic hematogenous osteomyelitis of tibia in 1 case, chronic infection in diabetic foot in 1 case. Adequate tissue specimen for bacteriology was taken during operation and selection of bacteria strains was subsequently done and appropriate phage were cultured. Phage were taken orally by patients 4–6 weeks after operation. Despite of paralel phage and systemic antibiotic administration all patients underwent operative debridement of infected bone. Simultaneously, every 7 days parameters of immunological response was measured in peripheral blood. They were: lymphocyte B activity (PFC and SAC test), lymphocyte T (NK) activity and phagocytose stimulation (PMA 30 test). There was a two-fold increase of lymphocyte B activity in PFC test with peak on day 7 after phage administration. Additionally slightly increase of NK cells and phagocytic activity and both increase and decrease of lymphocyte B and T activity in SAC test was observed. Eventually remission of infection was achieved in 6 from 8 patients. It is difficult to state a correlation between in vitro bactericidal effect of bacteriophage, immunological stimulation in peripheral blood and clinical results achieved after both operative and antimicrobial therapy

Introduction: Deep periprosthetic infections are infrequent but devastating situations in total joint arthroplasty. During the last years the total number and the percentage of total joint infections with multiresistant bacteria has increased. The aim of this study was to investigate the antimicrobial activity of a new bone cement loaded with nanoparticulate silver against bacteria with different antibiotic resistance. Material and Methods: An in vitro proliferation test was used to test antimicrobial properties of 1% nanoparticulate silver bone cement, gentamicin-loaded, tobramycin-loaded and plain bone cement. This in vitro testing method consisted of two incubation steps. During the first step the tested bacteria could adhere to the bone cement surface. In the second step bacteria either seeded out of vital daughter cells in case of no antimicrobial effect of the cement or were killed by the antibacterial properties of the cement. Seeding out of daughter cells was detected by a microplate reading system resulting in specific time proliferation curves. Several staphylococci and gram-negative strains with different resistance profiles against methicillin, tobramycin, and gentamicin were tested including MRSA and MRSE. Results: 1% nanoparticulate silver bone cement showed bactericidal effect against all tested strains, including MRSA and MRSE. Gentamicin and tobramycin cement was not effective against bacteria with high resistance level against the respective antibiotic. Plain bone cement was not effective against any strain. Conclusion: 1% nanoparticulate silver bone cement exhibited excellent antibacterial properties that could not be reached by gentamicin or tobramycin-loaded cement. Good activity against MRSA could also already be shown in a first animal trial. If further in vivo investigations confirm these promising results nanoparticulate silver bone cement is a new alternative for prophylaxis in total joint arthroplasty

Introduction: One of the primary complications in total hip and knee arthroplasty is infection. One of the major risk factors for deep periprosthetic infection is wound infection. This alone is associated with a substantial morbidity-increase which, in turn, increases hospital admittance time and therefore adds significant costs to the healthcare system. The aim of this study is to determine whether contamination of instruments used during primary insertion of a prosthesis, can be considered an early indicator for the occurrence of prolonged wound discharge. Early antibiotic treatment could then prevent this and decrease hospital admittance time and costs to the health care system. Material and Methods: During 121 procedures, swabs were taken from the first unused broach at the beginning and at the end of the procedure. Removed material from the bone (acetabulum and femur in the hip joint; femur and tibia in case of the knee joint) was tested for contamination as well. During 50 procedures a control swab was taken. The patients on the ward were also monitored to find out whether prolonged wound discharge occurred and to see after how many days the patients were discharged. Results: In 46 cases (38%) at least one culture showed microbial growth. In the other 75, there was no growth at all. If one of the cultures is positive, there is a 52% risk of prolonged wound discharge. Ifall cultures are negative, this risk is reduced to 13% (Chi-square: PO.001). Patients with a positive peroperative culture have to remain in the hospital for an additional 2.4 days (T-test: P-0.001). Conclusion: Peroperative culturing during primary insertion of a knee or hip prosthesis, provides a reliable tool to predict postoperative duration of wound discharge and hospital-admittance time

The April 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Do technical errors determine outcomes of operatively managed femoral neck fractures in younger adults?; Single-stage or two-stage revision for hip prosthetic joint infection (INFORM); Fixation better than revision in type B periprosthetic fractures of taper slip stems; Can you maximize femoral head size at the expense of liner thickness?; Plasma D-dimer for periprosthetic joint infection?; How important is in vivo oxidation?; Total hip arthroplasty for HIV patients with osteonecrosis.