There is an increasing incidence of revision for periprosthetic joint infection. The addition of vancomycin to beta-lactam antimicrobial prophylaxis in joint arthroplasty may reduce surgical site infections, however, the efficacy and safety have not been established. This was a multicenter, double-blind, superiority, placebo-controlled trial. We randomized 4239 adult patients undergoing joint arthroplasty surgery to receive 1.5g vancomycin or normal saline placebo, in addition to standard cefazolin antimicrobial prophylaxis. The primary outcome was surgical site infection at 90-days from index surgery. Perioperative carriage of Staphylococcus species was also assessed. In the 4113 patients included in the modified intention-to-treat population, surgical site infections occurred in 72/2069 (3.5%) in the placebo group and 91/2044 (4. 5%) in the vancomycin group (risk ratio 1.28; 95% confidence interval 0.94 to 1.73; p value 0.11). No difference was observed between the two groups for primary hip arthroplasty procedures. A higher proportion of infections occurred in knee arthroplasty patients in the vancomycin group (63/1109 [4.7%]) compared with the placebo group (42/1124 [3.7%]; risk ratio 1.52; 95% confidence interval 1.04 to 2.23; p value 0.031). Hypersensitivity reactions occurred in 11 (0.5%) patients in the placebo group and 24 (1.2%) in the vancomycin group (risk ratio 2.20; 95% confidence interval 1.08, 4.49) and acute kidney injury in 74 (3.7%) patients in the placebo group and 42 (2.1%) in the vancomycin group (risk ratio 0.57; 95% confidence interval 0.39, 0.83). Perioperative Staphylococcus aureus carriage was detected in 1089/3748 (29.1%) of patients. This is the first randomized controlled trial examining the addition of a glycopeptide antimicrobial to standard beta-lactam surgical antimicrobial prophylaxis in joint arthroplasty. The addition of vancomycin to standard cefazolin prophylaxis was not superior to placebo for the prevention of surgical site infections in hip and knee arthroplasty surgery

Introduction. PJI is a devastating complication following total joint arthroplasty. In this study, we explore the efficacy of a bacteriophage-derived lysin, PlySs2, against in-vitro biofilm on titanium implant surfaces and in an acute in-vivo murine debridement antibiotic implant retention (DAIR) model of PJI. Methods. In-vitro: Xen 36 S. aureus biofilm was grown on Ti-6Al-4V mouse tibial implants for 1 day or 5 days and subsequently exposed to growth media, 1000× minimal inhibitory concentration (MIC) Vancomycin, or 5× MIC PlySs2. Implants were sonicated and analyzed for Colony Forming Units (CFU). In-vivo: A Ti-6Al-4V implant was inserted into the proximal tibia of C57BL/6J mice (n=21). All mice received 10. 4. CFU inoculation of Xen 36 S. aureus to the knee joint capsule and the infection was permitted 5 days to progress. On day 5 the mice were separated into three groups (n=7/group): (1) no further surgical intervention (control group), (2) irrigation and debridement (I&D) with saline, (3) I&D with 2mg/mL PlySs2. No implant-exchange was performed to mimic a debridement, antibiotic, and implant retention (DAIR) therapeutic strategy. All mice were sacrificed at day 10. Results. CFU counts for 1-day and 5-day in-vitro grown biofilm on implants demonstrate a >3log-fold reduction with PlySs2 compared to Vancomycin (p=0.01) with no significant difference between Vancomycin and control. In-vivo the addition of PlySs2 to Vancomycin treated mice reduces bacterial load in the periposthetic tissue and implant (p<0.05) with 5 days of treatment. Conclusion. PlySs2 5× MIC exhibits superior anti-microbial effect compared to Vancomycin on implants with 1-day and 5–5day biofilm maturities. The addition of PlySs2 to Vancomycin treatment of an acute established PJI further reduces tissue CFU and implants CFU. For any tables or figures, please contact the authors directly

Introduction. Vancomycin is commonly added to acrylic bone cement during revision arthroplasty surgery. Proprietary cement preparations containing vancomycin are available but significantly more expensive. We investigated whether the antibiotic elution and mechanical strength of ‘home-made’ vancomycin containing bone cement was comparable to commercial vancomycin-impregnated cement. Methods. A total of 18 cement discs of constant size, containing either proprietary CopalG+V. ®. ; or ‘home-made’ CopalR+G. ®. with vancomycin added by hand, were made. Each disc contained the same antibiotic quantities (0.5g gentamycin, 2g vancomycin) and was immersed in ammonium acetate buffer in a sealed container. Fluid from each container was sampled at eight time points over a two week period. The concentration of gentamicin and vancomycin in the fluid was analysed using high performance liquid chromatography mass spectrometry. The impact strength of each PMMA cement preparation was measured using a Charpy-type impact tester. Results. Highest peak antibiotic concentrations were observed from the ‘home-made’ vancomycin containing cement, added as in the operating theatre. Overall antibiotic elution was, five-fold (vancomycin) and two-fold (gentamicin), greater from the ‘home-made’ mix compared to commercially mixed cement. However the ‘home-made’ cements showed greater variation in elution kinetics compared to the commercial mix. Use of a vacuum during mixing had no significant effect on antibiotic elution in any of the samples. Impact strength testing showed no significant differences between the groups. Discussion. Our findings suggest the addition of 2g vancomycin powder to gentamicin-impregnated bone cement in theatre, significantly increases elution of both antibiotics, with no significant loss of strength, compared to commercially prepared cement. Conclusion. We have found no significant advantages of expensive off-the-shelf vancomycin-impregnated bone cement and recommend the addition of vancomycin powder by hand when making cement beads and spacers

Aims. Current treatments of prosthetic joint infection (PJI) are minimally effective against Staphylococcus aureus biofilm. A murine PJI model of debridement, antibiotics, and implant retention (DAIR) was used to test the hypothesis that PlySs2, a bacteriophage-derived lysin, can target S. aureus biofilm and address the unique challenges presented in this periprosthetic environment. Methods. The ability of PlySs2 and vancomycin to kill biofilm and colony-forming units (CFUs) on orthopaedic implants were compared using in vitro models. An in vivo murine PJI model of DAIR was used to assess the efficacy of a combination of PlySs2 and vancomycin on periprosthetic bacterial load. Results. PlySs2 treatment reduced 99% more CFUs and 75% more biofilm compared with vancomycin in vitro. A combination of PlySs2 and vancomycin in vivo reduced the number of CFUs on the surface of implants by 92% and in the periprosthetic tissue by 88%. Conclusion. PlySs2 lysin was able to reduce biofilm, target planktonic bacteria, and work synergistically with vancomycin in our in vitro models. A combination of PlySs2 and vancomycin also reduced bacterial load in periprosthetic tissue and on the surface of implants in a murine model of DAIR treatment for established PJI. Cite this article: Bone Joint J 2020;102-B(7 Supple B):3–10

Aims. Periprosthetic joint infections (PJIs) with prior multiple failed surgery for reinfection represent a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion in treating this condition. Methods. A retrospective analysis included 78 PJI patients (29 hips; 49 knees) who had undergone multiple prior surgical interventions. Our cohort was treated with single-stage revision using a supplementary intra-articular antibiotic infusion. Of these 78 patients, 59 had undergone more than two prior failed debridement and implant retentions, 12 patients had a failed arthroplasty resection, three hips had previously undergone failed two-stage revision, and four had a failed one-stage revision before their single-stage revision. Previous failure was defined as infection recurrence requiring surgical intervention. Besides intravenous pathogen-sensitive agents, an intra-articular infusion of vancomycin, imipenem, or voriconazole was performed postoperatively. The antibiotic solution was soaked into the joint for 24 hours for a mean of 16 days (12 to 21), then extracted before next injection. Recurrence of infection and clinical outcomes were evaluated. Results. A total of 68 patients (87.1%) were free of infection at a mean follow-up time of 85 months (24 to 133). The seven-year infection-free survival was 87.6% (95% confidence interval (CI) 79.4 to 95.8). No significant difference in infection-free survival was observed between hip and knee PJIs (91.5% (95% CI 79.9 to 100) vs 84.7% (95% CI 73.1 to 96.3); p = 0.648). The mean postoperative Harris Hip Score was 76.1 points (63.2 to 92.4) and Hospital for Special Surgery score was 78. 2 (63.2 to 92.4) at the most recent assessment. Polymicrobial and fungal infections accounted for 14.1% (11/78) and 9.0% (7/78) of all cases, respectively. Conclusion. Single-stage revision with intra-articular antibiotic infusion can provide high antibiotic concentration in synovial fluid, thereby overcoming reduced vascular supply and biofilm formation. This supplementary route of administration may be a viable option in treating PJI after multiple failed prior surgeries for reinfection. Cite this article: Bone Joint J 2022;104-B(7):867–874

Treatment of periprosthetic joint infection (PJI) can include local delivery of antibiotics. A frequently used medium is absorbable calcium sulphate beads. The aims of this study were to:. identify how often organisms in infected THRs are sensitive to the added antibiotics. establish the incidence of persistent wound discharge and hypercalcaemia. All patients who received an antibiotic loaded calcium sulphate carrier (Stimulan, Biocomposites, Keele, UK) for either confirmed infection, presumed infection or for prophylaxis between July 2015 and July 2020 were included. Stimulan use was at the discretion of the surgeon, and between 10 and 40cc was used. In the absence of a known organism we routinely used 1g vancomycin and 240mg gentamicin per 10 cc of calcium sulphate. Post-operative sensitivities for all organisms cultured were compared to the antibiotics delivered locally. Persistent wound drainage was defined as discharge beyond the third postoperative day. Patients had serum calcium measured if they developed symptoms consistent with hypercalcaemia (Ca >2.6 mmol/L) or the clinical team felt they were at high risk. 189 patients (mean age 66.9 years, mean BMI 28.9, 85 male, 104 female) were included. 11 patients had a native joint septic arthritis, 42 presented with acute PJI and 136 presented with chronic PJI. 133 patients grew an organism, of which 126 were sensitive to the added antibiotics. Of the seven patients with resistant growth five had vancomycin-resistent Enterococcus, one Pseudomonas and one multi-organism growth including coagulase negative Staphylococcus. 40 patients experienced persistent wound discharge, with eight requiring re-operation. All other cases settled with dressing management. 12 patients developed hypercalcaemia (3/64 10cc, 7/117 20cc, 0/2 30cc and 2/6 40cc). The peak calcium reading ranged between the second and twelfth post-operative day. The addition of vancomycin and gentamicin to absorbable calcium sulphate covers the majority of organisms found in culture positive infection in our cohort. It also appears safe, with an acceptable incidence of hypercalcaemia or wound discharge. Further work is required to identify patients at greatest risk of culturing resistant organisms or delayed wound healing

The gold standard for PJI treatment comprises the use of antibiotic-loaded bone cement spacers, which are limited in their load bearing capacity[1]. Thus, developing an antibiotic-eluting UHMWPE bearing surface can improve the mechanical properties of spacers and improve the quality of life of PJI patients. In this study, we incorporated vancomycin into UHMWPE to investigate its elution characteristics, mechanical properties and its efficacy against an acute PJI in an animal model. Vancomycin hydrochloride was incorporated into UHMWPE (2 to 14%) by blending and consolidation. We studied drug elution with blocks in PBS and UV-Vis spectroscopy at 280 nm. We determined the tensile mechanical properties and impact strength [3]. We implanted osteochondral plugs in rabbits using either control UHMWPE, bone cement (40g) containing vancomycin (1g) and tobramycin (3.6g) or vancomycin-eluting UHMWPE (n=5) plugs in the patellofemoral groove of rabbits. All rabbits received a beaded titanium rod in the tibial canal. All groups received two doses of 5×10. 7. cfu of bioluminescent S. aureus in the distal tibial canal prior to insertion of the rod and the articular space after closure of the joint capsule. No intravenous antibiotics were used. Bioluminescence signal was measured when the rabbits expired, or at 21-day post-op. Hardware, polyethylene implants, and joint tissues were sonicated to further quantify live bacteria via plate seeding. Vancomycin elution increased with increasing drug loading. Vancomycin elution above MIC for 3 weeks and optimized mechanical properties were obtained at 6–7 wt% vancomycin loading in UHMWPE. In our lapine acute infection model using bioluminescent S. aureus, knees treated with UHMWPE without antibiotics and bone cement containing vancomycin and tobramycin had significantly higher bioluminescence compared to those treated with vancomycin-eluting UHMWPE. These results suggest that an antibiotic-eluting UHMWPE spacer with acceptable properties as a bearing surface could be used to treat periprosthetic joint infection in lieu of bone cement spacers and this could allow safer load bearing and a higher quality of life for the patients during treatment. In addition, this presents a safer alternative in cases where the second stage surgery for the implantation of new components is hindered

Prosthetic joint infections (PJIs) with prior multiple failed surgeries for re-infection (PMFSR) represented a huge challenge for surgeons because of poor vascular supply and biofilm formation. This study aims to determine the results of single-stage revision using intra-articular antibiotic infusion for treatment of PJIs with PMFSR. A retrospective analysis included 78 PJIs (29 hips; 49 knees) with PMFSR, who were treated with single-stage revision using intra-articular antibiotic infusion. Previous failure was defined as infection recurrence requiring surgical intervention. Besides intravenous pathogen-sensitive agents, a intra-articular infusion of vancomycin, imipenem or voriconazole was performed post-operatively. The antibiotic solution was soaked into the joint for 24 hours then extracted before next injection. Recurrence of infection and clinical outcomes were evaluated. Of these 78 patients, 59 had more than twice failed debridement and implant retentions, 12 patients had a failed arthroplasty resection, 3 hips underwent a failed two-stage revision and 4 cases had a failed one-stage revision before their single-stage revision. A total of 68 patients (87.1%) were free of infection at a mean follow-up time of 85 months. No significant difference in infection control rate was observed between hip and knee PJIs (89.7% versus 85.7%). The mean postoperative Harris hip score was 76.1 points and HSS score was 78. 2 at the most recent assessment. Single-stage revision with intra-articular antibiotic infusion can provide high antibiotic concentration in synovial fluid therefore overcome poor vascular supply and biofilm formation, which can be a viable option in treating PJI with PMFSR

Aims. Single-stage revision is not widely pursued due to restrictive inclusion criteria. In this study, we evaluated the results of single-stage revision of chronically infected total hip arthroplasty (THA) using broad inclusion criteria and cementless implants. Patients and Methods. Between 2010 and 2016, 126 patients underwent routine single-stage revision with cementless reconstruction with powdered vancomycin or imipenem poured into the medullary cavity and re-implantation of cementless components. For patients with a culture-negative hip, fungal infections, and multidrug-resistant organisms, a direct intra-articular infusion of pathogen-sensitive antibiotics was performed postoperatively. Recurrence of infection and clinical outcomes were evaluated. Three patients died and 12 patients (none with known recurrent infection) were lost to follow-up. There were 111 remaining patients (60 male, 51 female) with a mean age of 58.7 (. sd. 12.7; 20 to 79). Results. Of these 111 patients, 99 (89.2%) were free of infection at a mean follow-up time of 58 months (24 to 107). A recurrent infection was observed in four of the 23 patients (17.4%) with culture-negative infected hip. The success rate in patients with multidrug-resistant organisms was 84.2% (16/19). The mean postoperative Harris hip score was 79.6 points (63 to 92) at the most recent assessment. Conclusion. Routine single-stage revision with cementless reconstruction can be a viable option for the treatment of chronically infected THA. The results of this study will add to the growing body of evidence supporting routine use of single-stage revision for the treatment of chronically infected THA. Cite this article: Bone Joint J 2019;101-B:396–402

Previous studies showed that a fast-resorbable antibacterial hydrogel coating (DAC®, Novagenit Srl, Mezzolombardo, TN, Italy) composed of covalently linked hyaluronan and poly-D, L-lactide, is able to reduce early post-surgical infection both after joint replacement and osteosynthesis. Aim of the present report is to investigate medium-term safety and efficacy of the coating in patients undergoing primary and revision cementless total hip replacement (THR). We designed a two-phases study. In both phases, DAC was prepared according to manufacturer's instructions. In brief, the syringe prefilled with 300 mg of sterile DAC powder was mixed, at the time of surgery, with a solution of 5 mL of sterile water and with the tailored antibiotics, at a concentration ranging from 25 mg/mL to 50 mg/mL. The resulting antibacterial hydrogel was then spread on the outer surface of the prosthesis just before implantation. In the first phase, safety was assessed. Forty-six patients (13 primary and 33 revision THR) were treated with DAC between 2013 and 2015 and evaluated at a 2.8 ± 0.7 years follow up (FU). Antibiotics used for DAC reconstruction were Vancomycin in 33 cases, Vancomycin + Meropenem in 10, Vancomycin + Rifampicin, Teicoplanin or Ceftazidime in 1 case, respectively. Patients were evaluated at 3, 6, 12 months and yearly after with a clinical and radiographic FU. No evidence of infection and no failure/loosening of the prosthesis were observed. No adverse events were reported. The second phase was designed to evaluate efficacy of DAC in preventing infection recurrences after a two stage revision for infected THR. Twenty-seven patients, treated with DAC coating, were compared with a control group of 32, treated in the same time period, without the coating. Demographics, host type and and identified bacteria were similar in the two groups (18.6% of MRSA in DAC group vs 18.5% MRSA in no-DAC group). Patients were evaluated clinically and radiographically at 3, 6, 12 months and yearly thereafter. At a minimum 2 years FU (mean 2.7), we observed 1 dislocation in each group and 2 cases of loosening in the no-DAC group. 4 cases (11%) of recurrence of infection in the no-DAC group (1 MRSA and 3 St. Epidermidis) and no infection recurrences in the DAC group. Due to the small cohort of patients this difference is not statistically significant (Fisher's exact test, p=0.18). This is, to our knowledge, the longest observation concerning the safety and efficacy of the DAC antibacterial coating, applied to hip replacement. The results are in line with those previously reported and point out the absence of side effects of the antibacterial coating in this application and the tendency to reduce re-infection in second stage. This finding needs to be confirmed by a larger dataset

Aims. We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. Patients and Methods. A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, . sd. 12.3) and 28.8 kg/m. 2. (13.3 to 57.6, . sd. 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. Results. There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. Conclusion. We found a higher rate of PJI in DA versus NA approaches. Infection prevention protocols such as use of aspirin, dilute povidone-iodine lavage, vancomycin powder, and Gram-negative coverage may have been positively associated with diminished PJI rates observed for all approaches over time. Cite this article: Bone Joint J 2019;101-B(6 Supple B):2–8

Aims

A revision for periprosthetic joint infection (PJI) in total hip arthroplasty (THA) has a major effect on the patient’s quality of life, including walking capacity. The objective of this case control study was to investigate the histological and ultrastructural changes to the gluteus medius tendon (GMED) in patients revised due to a PJI, and to compare it with revision THAs without infection performed using the same lateral approach.

Aims

Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution.

When using a staged approach to eradicate chronic infection after total hip replacement, systemic delivery of antibiotics after the first stage is often employed for an extended period of typically six weeks together with the use of an in situ antibiotic-eluting polymethylmethacrylate interval spacer. We report our multi-surgeon experience of 43 consecutive patients (44 hips) who received systemic vancomycin for two weeks in combination with a vancomycin- and gentamicin-eluting spacer system in the course of a two-stage revision procedure for deep infection with a median follow-up of 49 months (25 to 83). The antibiotic-eluting articulating spacers fractured in six hips (13.9%) and dislocated in five patients (11.6%). Successful elimination of the infecting organisms occurred in 38 (92.7%) of 41 hips with three patients developing superinfection with a new organism. We conclude that prolonged systemic antibiotic therapy may not be essential in the two-stage treatment of a total hip replacement for Gram-positive infection, provided that a high concentration of antibiotics is delivered locally using an antibiotic-eluting system

Aims

Dislocation remains a leading cause of failure following revision total hip arthroplasty (THA). While dual-mobility (DM) bearings have been shown to mitigate this risk, options are limited when retaining or implanting an uncemented shell without modular DM options. In these circumstances, a monoblock DM cup, designed for cementing, can be cemented into an uncemented acetabular shell. The goal of this study was to describe the implant survival, complications, and radiological outcomes of this construct.

Aims

Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects.

Aims

The duration of systemic antibiotic treatment following first-stage revision surgery for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is contentious. Our philosophy is to perform an aggressive debridement, and to use a high local concentration of targeted antibiotics in cement beads and systemic prophylactic antibiotics alone. The aim of this study was to assess the success of this philosophy in the management of PJI of the hip using our two-stage protocol.

Bone allografts can store and release high levels of vancomycin. We present our results of a two-stage treatment for infected hip arthroplasty with acetabular and femoral impaction grafting using vancomycin-loaded allografts. We treated 29 patients (30 hips) by removal of the implants, meticulous debridement, parenteral antibiotic therapy and second-stage reconstruction using vancomycin-supplemented impacted bone allografts and a standard cemented Charnley femoral component. The mean follow-up was 32.4 months (24 to 60). Infection control was obtained in 29 cases (re-infection rate of 3.3%; 95% confidence interval 0.08 to 17) without evidence of progressive radiolucent lines, demarcation or graft resorption. One patient had a further infection ten months after revision caused by a different pathogen. Associated post-operative complications were one traumatic periprosthetic fracture at 14 months, a single dislocation in two hips and four displacements of the greater trochanter. Vancomycin-supplemented allografts restored bone stock and provided sound fixation with a low incidence of further infection

Although single-stage revision has attracted a lot of attention due to less socioeconomic cost, this technique is not widely used throughout the world due to strict indications. In this situation, we report our outcome on single-stage revision combined with selective direct intra-articular antibiotic infusion for chronic infected THA, especially for patients with culture-negative hip, fungal infections and multidrug-resistant organism. We retrospectively reviewed 131 patients with chronic infected THA between January 2010 and February 2017 who underwent single-stage revision, including soakage of surgical area with 0.5% aqueous betadine, pouring powdered vancomycin or imipenem into the medullary cavity. For patients with culture-negative hip, fungal infections and multidrug-resistant organism, a direct intra-articular infusion of pathogens-sensitive antibiotics via three-branch catheter were performed postoperatively. Recurrence of infection and clinical outcomes were evaluated. One hundred and fifteen patients were followed-up for an average of 4.5 years (range, 1.2–8 years). Of the 115 patients, 103 patients (89.6%) required no additional surgical or medical treatment for recurrence of infection. A recurrent infection was observed in 4 of the 23 patients (17.4%) with culture-negative infected hip. One of 4 fungal infections was relapse and the success rate in patients with multidrug-resistant organism was 84.2% (16/19). The mean postoperative Harris hip score was 81 points (63 to 92; p < 0.05) at the most recent assessment. Treatment of chronic infected THA by single-stage revision combined with selective direct intra-articular antibiotic infusion can be fairly effective, even for patients with relative “contraindication” of this approach

Aims

There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients.