Aim. Patients with late acute periprosthetic joint infections (PJI) and treated with surgical debridement have a high failure rate. Previous studies have shown that rheumatoid arthritis (RA) is an independent risk factor for treatment failure. We conducted a case-control study to identify predictors for failure in late acute PJI treatment in RA patients. We hypothesize that patients with RA have a higher failure rate compared to controls due to the use of immunosuppressive drugs. Method. Data of an international multicenter retrospective observational study was used. Late acute PJI was defined as a sudden onset of symptoms and signs of a PJI, more than 3 months after implantation. Failure of treatment was defined as persistent signs of infection, relapse with the same or reinfection with a different micro-organism, need for prosthesis removal or death. Cases with RA were matched with cases without RA based on the affected joint. A Cox survival analyses, stratified for RA, was used to calculate hazard ratio's (HR) for failure. Subgroup analyses were used to explore other predictors for treatment failure in RA patients. Results. A total of 40 patients with RA and 80 controls without RA were included. Treatment failure occurred in 65% patients with RA compared to 45% for controls (p= .052). 68% of patients with RA used immunosuppressive drugs at time of PJI diagnosis. The use or continuation of immunosuppressive drugs in PJI was not associated with a higher failure rate; neither were the duration of symptoms and causative microorganism. The time between implantation of the prosthetic joint and diagnosis of infection was longer in RA patients: median 110 (IQR 41-171) vs 29 months (IQR 7.5–101.25). Exchange of mobile components was associated with a lower risk of treatment failure (HR 0.489, 95% CI 0.242–0.989, p-value .047). Conclusions. The use of immunosuppressive drugs does not seem to be associated with a higher failure rate in patients with RA. Mobile exchange in RA patients is associated with a lower risk of failure. This might be due to the significantly older age of the prosthesis in RA patients. Future studies are needed to explore these associations and its underlying pathogenesis

Aim. Acute hematogenous periprosthetic joint infection (AHI) is a diagnosis on the rise. The management is challenging and the optimum treatment is not clearly defined. The purpose of this study was to evaluate the characteristics of AHI, and to study risk factors affecting treatment outcome. Methods. We retrospectively analysed 44 consecutive episodes with AHI in a total hip or knee arthroplasty beween 2013 and 2020 at a single center. AHI was defined as abrupt symptoms of infection ≥ 3 months after implantation in an otherwise well functioning arthroplasty. We used the Delphi criteria to define treatment failure with a minimum of 1-year follow-up. Results. AIH was most often caused by Staphylococcus aureus (36%) and streptococcal species (32%), but a broad spectrum of microbes were identified. The majority of patients (25/44) were treated with debridement and retention of the implant (DAIR), with a success rate of 40%, significantly lower than in patients treated with removal of the implant (94%, p=0.001). Staph aureus infections (p=0.004), knee arthroplasties (p=0.03), and implant-age < 2 years (p=0.034) were associated with treatment failure. The 2-year mortality rate was 19%. Conclusions. The main findings in this study were that outcome following DAIR in AHIs is poor, that the majority of infections were caused by virulent microbes, and we found a high mortality rate. Removal of the implant should more often be considered

The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed.

We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission.

A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001).

This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI.

Acute postoperative periprosthetic joint infection (PJI) is a serious complication after any hemiarthroplasty (HHA) implanted due to a proximal hip fracture. The growing number of chronic institutionalized geriatric patients (CIGP) colonized with multi-drug resistant bacteria (e.g.: MRSA), not covered by usual antibiotic prophylaxis, has been identified as a risk factor for PJI after HHA. We therefore sought to compare the HHA infection characteristics between non-institutionalized patients (NIP) with proximal hip fractures and CIGP. We investigate (1) the rate of compliance with a new proposed protocol, (2) the acute infection rate, 3) the microbiologic characteristics of the infection, and 4) the success of the new protocol. We gathered clinical, operative and infection data on all patients who underwent HHA due to a proximal femoral fracture in our center, during a 3-year period. We focus in the cases of acute postoperative infection (Zimmerli´s criteria). The new proposed antibiotic prophylaxis is cefazolin except in CIGP in which co-trimoxazole is used. During the study period a total of 385 HHA in 385 patients were performed. In all cases the HHA was performed after a proximal femoral fracture. Overall, 109 patients (28,2%) were CIGP. We found an acute postoperative PJI in 21 out 385 HHA procedures, that is, a global acute infection rate of 5.43%. Ten out 109 (9.17%) CIGP patients resulted infected compared to 11 out 278 (3.9%) non-institutionalized patients (p: 0.049). One or more causative microorganisms were identified in 20/21 (95%) of PJI. Globally the Gram-Negative bacilli group accounted for the majority of the infections (60%). Staphylococus aureus was isolated in 3 cases (8.6%) with only a single MRSA infection. The percentage of polymicrobial infections was 47% (10 out of 21). Co-trimoxazole was used in the prophylaxis in 80.1% of the CIGP. In the infected cases a non-effective drug against the microorganism was used in the prophylaxis in 17 (81%) of the acute infected HHA. We confirm that institutionalized patients are more prone to acute infections after a HHA. Our current strategy of antibiotic prophylaxis has showed to be effective in preventing MRSA PJI in CIGP. However, we found an increased rate of infection due to gram-negative bacilli non-covered by the current antibiotic prophylaxis. According our data an extended antibiotic prophylaxis on gram-negative drug will be proposed to be implemented in CIGP scheduled to a HHA because a proximal femoral fracture

Aim. Debridement, antibiotics, and implant retention (DAIR) is a viable treatment option for acute periprosthetic joint infections (PJI). The landmark DATIPO trial of Bernard et al. concluded that six weeks is not non-inferior to 12-week antibiotic therapy for DAIR. However, it is unknown if suppressive antibiotic treatment (SAT) would improve patient outcomes. Therefore, our study aims to evaluate the utility of SAT after 12 weeks of therapy. Method. We performed a retrospective study of patients with acute hip or knee PJI managed with DAIR at five institutions; in the U.S. (n=1), Netherlands (n=3), and Spain (n=1) from 2005–2020. We analyzed the effect of SAT using a Cox model among patients after 12 weeks of antibiotic treatment. The primary covariate of interest was whether the patient was on antibiotics after week 12, which was coded as a time-varying covariate. We decided a-priori to control for the clinically important risk factors such as age, sex, type of infection, modular exchange, joint, and presence of bacteremia and Staphylococcus aureus. We excluded patients who died, had treatment failure, or were lost to follow-up before 12 weeks. We defined treatment failure as infection recurrence (same or different organism), unexpected reoperation, or death due to infection. Results. There were 504 patients included in the study. The majority were female (58%, n=292), with a mean age of 70 years ago (SD 11). Hips and knees were equally proportioned. Primary arthroplasties represented 69% of the total cohort (n=349). Treatment failure was 11.9% in the total cohort (n=60). There was no statistically significant association between SAT after 12 weeks and treatment failure (HR 1.25, p=0.45, 95% CI 0.70–2.24). This finding was consistent across different subgroups, including hip or knee joints, early or late acute infections, cohort, and a subgroup of knee joints after 180 days. Conclusions. SAT after 12 weeks of antibiotic treatment for acute PJI managed with DAIR does not appear to improve patient outcomes

Aim. The gold standard treatment for late acute hematogenous (LAH) periprosthetic joint infection (PJI) is surgical debridement, antibiotics and implant retention (DAIR). However, this strategy is still controversial in the case of total knee arthroplasty (TKA) as some studies report a higher failure rate. The aim of the present study is to report the functional outcomes and cure rate of LAH PJI following TKA treated by means of DAIR at a long-term follow-up. Method. A consecutive prospective cohort consisting of 2,498 TKA procedures was followed for a minimum of 10 years (implanted between 2005 and 2009). The diagnosis of PJI and classification into LAH was done in accordance with the Zimmerli criteria (NEJM 2004). The primary outcome was the failure rate, defined as death before the end of antibiotic treatment, a further surgical intervention for treatment of infection was needed and life-long antibiotic treatment or chronic infection. The Knee Society Score (KSS) was used to evaluate clinical outcomes. Surgical management, antibiotic treatment, the source of infection (primary focus) and the microorganisms isolated were also assessed. Results. Among the 2,498 TKA procedures, 10 patients were diagnosed with acute hematogenous PJI during the study period (0.4%). All those 10 patients were operated by means of DAIR, which of course included the polyethylene exchange. They were performed by a knee surgeon and/or PJI surgeon. The failure rate was 0% at the 8.5 years (SD, 2.4) follow-up mark. The elapsed time between primary total knee replacement surgery and the DAIR intervention was 4.7 years (SD, 3.6). DAIR was performed at 2.75 days (SD 1.8) of the onset of symptoms. The most common infecting organism was S. aureus (30%) and E. coli (30%). There were 2 infections caused by coagulase-negative staphylococci and 2 culture-negative PJI. All culture-positive PJI microorganisms were susceptible to anti-biofilm antibiotics. The source of infection was identified in only 3 cases. The mean duration of antibiotic treatment was 11.4 weeks (SD 1.9). The postoperative clinical outcomes were excellent, with a mean KSS of 84.1 points (SD, 14.6). Conclusions. Although the literature suggests that TKA DAIR for acute hematogenous periprosthetic joint infection is associated with high rates of failure, the results presented here suggest a high cure rate with good functional outcomes. Some explanations for this disparity in results may be the correct diagnosis of LHA, not misdiagnosing acute chronic PJI, and a thorough debridement by surgeons specialized in PJI

Effectiveness of Liposomal Bupivacaine for Post-Operative Pain Control in Total Knee Arthroplasty: A Prospective, Randomised, Double Blind, Controlled Study. Pericapsular Injection with Free Ropivacaine Provides Equivalent Post-Operative Analgesia as Liposomal Bupivacaine following Unicompartmental Knee Arthroplasty. Total Knee Arthroplasty in the 21st Century: Why Do They Fail? A Fifteen-Year Analysis of 11,135 Knees. Cryoneurolysis for Temporary Relief of Pain in Knee Osteoarthritis: A Multi-Center, Prospective, Double-Blind, Randomised, Controlled Trial. Pre-Operative Freezing of Sensory Nerves for Post-TKA Pain: Preliminary Results from a Prospective, Randomised, Double-Blind Controlled Trial. Proximalization of the Tibial Tubercle Osteotomy: A Solution for Patella Infera during Revision Total Knee Arthroplasty. Treatment of Periprosthetic Joint Infection Based on Species of Infecting Organism: A Decision Analysis. Alpha-Defensin Test for Diagnosis of PJI in the Setting of Failed Metal-on-Metal Bearings or Corrosion. Risk of Reinfection after Irrigation and Debridement for Treatment of Acute Periprosthetic Joint Infection following TKA. Serum Metal Levels for the Diagnosis of Adverse Local Tissue Reaction Secondary to Corrosion in Metal-on-Polyethylene Bearing Total Hip Arthroplasty. Intra-Articular Injection for Painful Hip OA - A Randomised, Double-Blinded Study. Six-Year Follow-up of Hip Decompression with Concentrated Bone Marrow Aspirate to Treat Femoral Head Osteonecrosis. No Benefit of Computer-Assisted TKA: 10-Year Results of a Prospective Randomised Study

Aim. Rifampin is considered as the antibiotic corner stone in the treatment of acute staphylococcal periprosthetic joint infections (PJI). However, if, when, and how to use rifampin has been questioned. We evaluated the outcome of patients treated with and without rifampin, and analysed the influence of timing, dose and co-antibiotic. Method. Acute staphylococcal PJIs treated with surgical debridement between 1999 and 2017, and a minimal follow-up of 1 year were evaluated. Treatment failure was defined as the need for any further surgical procedure related to infection, PJI-related death, or the need for suppressive antimicrobial treatment. Results. A total of 669 patients were analysed. Treatment failure was 32.2% (131/407) in patients treated with rifampin and 54.2% (142/262) in whom rifampin was withheld (P < 0.001). The most prominent effect of rifampin was observed in knees (treatment failure 28.6% versus 63.9%, respectively, P < 0.001). The use of rifampin was an independent predictor of treatment success in the multi-variate analysis (OR 0.30, 95% CI 0.20 – 0.45). In the rifampin group, the use of a co-antibiotic other than a fluoroquinolone (OR 7.73, 95% CI 4.26 – 14.0) and the start of rifampin within 5 days after surgical debridement (OR 1.88, 95% CI 1.05 – 3.35) were predictors of treatment failure. Clindamycin demonstrated similar efficacy as co-antibiotic. The dosing of rifampin had no effect on outcome. Conclusions. Our data supports the use of rifampin in acute staphylococcal PJIs treated with surgical debridement, particularly in knees. Immediate start of rifampin after surgical debridement should probably be discouraged

Objectives. C-reactive protein(CRP) Used as screening test for acute periprosthetic joint infection has high sensitivity and low specificity. So there are many reasons except acute infection after total knee arthroplasty to elevate CRP level but it is unclear what reasons exactly were concerned. We therefore performed this study to determine the Causes of elevated CRP level in the early-postoperative period after primary total knee arthroplasty. Methods. Between 2005 and 2013, 502 patients undergone primary total knee arthroplasty were included. We excluded patients performed total knee arthroplasty with inflammatory arthritis and revision total knee arthroplasty, We measured the serial CRP levels in the all cases and then found cases with CRP level show elevation-depression-elevation pattern(bimodal graph) or >23.5mg/dl. We analyzed causes of elevated CRP level of that. Results. 66 patients represented bimodal pattern CRP graph. Elevation caused by periprosthetic infection were 16, Deep vein thrombosis were 10, Gastrointestinal problem were 8, urogenital cause were 10, respiratory infection was 10 and Unknown causes were 11. Conclusions. We had to know that Elevated CRP level after total knee arthroplasty can be caused by various general conditions including deep vein thrombosis can be a one of the origin elevating CRP & gastrointestinal problem, urogenital problem, respiratory infection

Purpose. The success rate of surgical debridement and prostheses retention for acute periprosthetic joint infection (PJI) is controversial. This study aims to report our experience in managing acute PJI following total knee arthroplasty (TKA) with surgical debridement and prostheses retention, and to identify the prognostic factors that may influence the surgical outcomes. Methods. A retrospective review from our prospective joint replacement register in Queen Mary Hospital, Hong Kong, of patients who were managed with surgical debridement and prosthesis retention for acute PJI after TKA between 1998 and 2013 was performed. The diagnosis of acute PJI was based on the 2011 Musculoskeletal Infection Society (MSIS) PJI diagnostic criteria. Both the early post-operative infections and the late haematogenous infections were included (Tsukayama type 2 and 3). Surgical outcomes were defined as successful if patients’ clinical symptoms had been relieved; inflammatory marker levels including C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR) and White Blood Cell (WBC) count had returned to normal; X-rays showed no prosthetic loosening; and no lifelong antibiotic suppression was required. Outcomes were defined as failed if patients required any further surgeries (e.g., re-debridement, one or two-stage revision), or needed lifelong antibiotic suppression. All Patients’ perioperative data, i.e., age, primary diagnosis, pre-operative CRP, ESR, WBC, haemoglobin, albumin, glucose level, time lag from symptoms onset to debridement, synovial fluid total cell count and bacteriology were traced and recorded. SPSS 22.0 was used to calculate and compare the statistical differences between surgically successful group and failed group regarding the factors above. Results. 34 patients with 35 TKAs were included. There were 19 female and 15 male. The primary diagnoses included 29 osteoarthritis (OA) and 5 rheumatoid arthritis (RA). 8 had history of diabetes mellitus (DM). 25 knees received primary TKA and 10 knees received revision TKA, including 6 revisions for PJI and 4 for aseptic loosening. 12 belonged to Tsukayama type 2 (early post-operative infection) and 23 belonged to Tsukayama type 3 (late haematogenous infection). During a mean follow-up time of 45.9±44.2 months, 12 were successfully treated while 23 failed, including 15 required re-operations and 8 needed lifelong antibiotic suppression. The success rate of debridement was 34.2%. Statistical analyses showed no significant differences between the two groups on patients’ age, time lag from symptoms onset to debridement, pre-operative CRP, ESR, WBC, haemoglobin, albumin, glucose level or synovial fluid total cell count. (Table 1) Patients’ primary diagnosis, previous revision surgeries or staphylococcal infections had no significant impacts on the surgical outcome, either. Debridement with polyethylene insert exchange, however, had a significantly higher success rate than debridement alone. (Table 2). Conclusions. We concluded that debridement with prosthesis retention has a low success rate for acute periprosthetic infection in TKA. No significant prognostic factors could be identified, except that debridement with polyethylene insert exchange has higher success rate than debridement alone

Aim. Treatment of complicated wound healing after total joint arthroplasty is controversial. What exactly constitutes prolonged wound drainage is matter of debate and recommendations to manage it vary considerably. Nonoperative measures are often recommended. If drainage persists, surgery may be indicated. To further intricate decision-making, differentiating superficial from deep surgical site infection is also controversial and inherently complex. Specific cutoffs for synovial fluid leukocyte count and blood C-reactive protein (CRP) in the acute stage have been suggested as a way to superficial infection requiring superficial wound washout from deep infection requiring a formal debridement, antibiotics and implant retention (DAIR) procedure. The goal of this study is to analyze clinical and laboratory findings of an institutional protocol of “aggressively” proceeding with formal DAIR in all patients with complicated wound healing. Method. Our indications for DAIR in suspected acute postoperative periprosthetic joint infection (PJI) are: 1)prolonged wound drainage and CRP upward trend after day-3; 2)persistent wound drainage by day-10 regardless of CRP; 3)wound healing disturbance (e.g. “superficial” infection, “superficial” skin necrosis) anytime in early postoperative weeks. We retrospectively evaluated patients undergoing DAIR in the first 60 postoperative days between 2014–2018. Patients without multiple deep tissue cultures obtained intraoperative were excluded. Deep infection was defined by at least two positive deep tissue cultures or one positive deep culture and positive leukocyte count (>10,000 cells/mL or >90% PMN). Results. A total of 44 DAIR procedures were included. Deep infection was confirmed in 79.5%(35/44) of cases. Mean CRP in infected cases was 93mg/L with 63%(19/30) of them below the 100 mg/L threshold. Unfortunately, only a small proportion of cases (10/44) had synovial fluid leukocyte counts available. Mean leukocyte count was 15,558 cells/mL and mean proportion of PMN was 65.3%. Of these ten, six confirmed deep infections were below the proposed >10,000 cells/mL or >90% PMN cutoff. Conclusions. Early diagnosis of acute postoperative PJI is often hampered by its very subtle presentation. This study confirms that more often than not, deep infection is present when facing complicated wound healing after total joint arthroplasty, supporting our institutional “aggressive” protocol. We have been surprised by the number of confirmed acute PJI with low blood CRP levels and low synovial leukocyte counts. We hypothesize that the proposed acute PJI specific thresholds may lead to misinterpret a significant proportion of cases as superficial infections thus compromising timely intervention. The findings of this study lack confirmation in larger cohorts

Historical perspective: Irrigation and debridement (I&D) with modular exchange has historically been the recommended treatment for acute post-operative periprosthetic joint infection (PJI), and acute hematogenous PJI. The theory supporting this practice was that because the bacterial glycocalyx had not yet formed by these early time points, by simply debriding the intra-articular bacterial load and exchanging the modular parts, one could potentially eradicate the infection, retain the prior components, and minimise morbidity to the patient. More recently, literature is coming out suggesting that this may not necessarily be the case. The vast majority of published research on the outcomes following I&D for treatment of PJI has focused on either cohorts of total knee arthroplasty patients or combined cohorts of total hip and knee patients. For this reason, it is difficult to tease out the differential success rate of periprosthetic hip vs. knee infections. Sherrell et al. performed a systematic review of the existing literature and created a table detailing the failure rates for various published articles on I&D for periprosthetic TKA infection. Since it is the glycocalyx that has been thought to be the reason for treatment failure of many cases of PJI treated with I&D, many authors have implicated staphylococcal species as a predictor of a negative outcome with failure rates ranging from 30–35%. Methicillin resistant organisms have been shown to be particularly difficult to eradicate with an isolated I&D, with a 72–84% failure rate at 2 year follow-up. Interestingly, a recent study by Odum et al. suggests that neither the infecting microbe, nor the antibiotic resistance profile of the organism, as has been classically thought, actually predicts success of I&D. Previous reports have indicated that the ability of I&D to control infection is related to the duration of symptoms and its timing relative to the index surgery. However, more recent literature is coming out to support the contrary. Koyonos et al. reviewed the outcomes of a series of 138 cases of PJI treated with I&D based on acuity of infection and concluded that an I&D has a limited role in controlling PJI regardless of acuity. Intuitively, the physical health of the host/patient should influence the success of I&D for treatment of PJI. Several authors have shown that an immunocompromised state is a predictor of treatment failure. Furthermore, Azzam et al. reported that patients with a higher American Society of Anesthesia (ASA) score, a proxy of severity of medical comorbidities, had a significantly higher failure rate. Although potentially appealing due to relative ease of execution and minimal surgical morbidity, the ability to successfully eradicate infection with an arthroscopic procedure may be compromised. Given the inability to perform a radical surgical debridement, nor exchange modular components, arthroscopic debridement should be used with extreme reservation in any case of PJI, regardless of the host, nature of the infecting organism, or acuity of infection. I&D as a conservative, less morbid alternative to two-stage exchange - There is a growing body of literature to suggest that an I&D with modular component exchange may not be the benign, less morbid alternative to the ‘gold standard’ two-stage exchange arthroplasty. In fact, Fehring et al. has reported that the success of a two-stage antibiotic spacer exchange arthroplasty may be compromised by an initial I&D. They found that patients who were initially treated with an I&D only had a 66% chance of eradicating infection following a two-stage exchange arthroplasty, in contrast to historical reports of 80–90% success

Aims

Orthopaedic infection is a potentially serious complication of elective and emergency trauma and orthopaedic procedures, with a high associated burden of morbidity and cost. Optimization of vitamin D levels has been postulated to be beneficial in the prevention of orthopaedic infection. This study explores the role of vitamin D in orthopaedic infection through a systematic review of available evidence.