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

We present a series of 114 patients with microbiologically-proven chronically-infected total hip replacement, treated between 1991 and 2004 by a two-stage exchange procedure with antibiotic-loaded cement, but without the use of a prolonged course of antibiotic therapy. The mean follow-up for all patients was 74 months (2 to 175) with all surviving patients having a minimum follow-up of two years. Infection was successfully eradicated in 100 patients (87.7%), a rate which is similar to that reported by others, but where prolonged adjuvant antibiotic therapy has been used. Using the technique described, a prolonged course of systemic antibiotics does not appear to be essential and the high cost of the administration of antibiotics can be avoided

The management of prosthetic joint infection (PJI) has been widely performed for total hip arthroplasties (THA), but none has compared it with hip resurfacing arthroplasty (RSA). We also carried out a retrospective case-control study comparing the surgical treatment of PJI by surgical debridement and implant retention between RSA and THA in order to clarify whether there was a difference in terms of (1) successful healing of PJI (2) functional scores after recovery (3) risk factors for recurrence of PJI. Our hypothesis was that simple debridement with prosthesis retention regardless of the timeframe allowed to obtain a higher success rate for RSA compared to THA. From 2010 to 2018, a single-center case-control study based on 3056 RSA found 13 PJI were age-matched (based on the 139 THA PJI treated) with 15 THA PJI (mean age of 53 years old (47–58) for THA and 59 (45–66) for RSA (p=0.34)). We compared their survival (absence of infectious recurrence) and the means differences between the 2 groups (demographical, clinical and biological data). There was no difference between the 2 groups concerning: age (p=0.3), BMI (p=0.4), initial diagnosis (p=0.4), operating time for primary surgery (p=0.3), the presence of a postoperative hematoma (p=0.4), the type of bacteria (p=0.5), the total duration of antibiotic therapy (p=0.9) and the type of antibiotic therapy (p=0.6). Early postoperative infections (less than 6 weeks) occurred in 7/13 RSA cases (54%) compared to 11/15 THA cases (73%). At the mean follow-up of 5 years (2–7), the success rate without recurrence was significantly higher in the RSA group 100% versus 66.7% (10/15) for the THA group (p=0.044). At the last follow-up, the Oxford Hip Score was higher in the RSA versus THA group's (14 versus 22 p=0.004). Simple surgical debridement an RSA without changing implants after PJI can be done regardless of the time to onset of infection. This is secondary to the absence of metaphyseal bone invasion and the low content of joint fluid

The increasing infection burden after hip arthroplasty has seen a growth of two-stage exchange and the use of increasingly powerful antibiotics at the time of this procedure. We have seen an increased number of failed two-stage revisions over the past decade. This study was aimed at clarifying the outcome of failed two-stage exchange arthroplasty after periprosthetic hip infection. We identified forty-two patients who had undergone at least one prior two-stage revision hip arthroplasty for periprosthetic infection between 2000 and 2012. These patients were referred to our center and treated with a further two-stage exchange. They have been analyzed with a minimum two-year follow-up. Control of infection at two-year follow-up was seen in 57% of patients. In 43% of patients there are still ongoing issues that either required further surgery or ongoing antibiotic suppression. A regression analysis was undertaken which suggested that the immunocompromised host and polymicrobial infection were the greatest predictors of failure. The number of previous interventions, the organism involved and the duration of antibiotic therapy after the initial two-stage revision were not linked to the ultimate outcome. The failure rate of repeat revision two-stage exchange is high and novel methods of treatment including host optimization, immunomodulation, longer interval periods, novel antimicrobial methods and more powerful antibiotic therapies should be investigated

Introduction. Prosthetic joint infection (PJI) is the leading cause of failure of primary and revision hip and knee arthroplasty. It is challenging condition which represents a growing burden on hospital resources. In-patient hospital stay for antibiotic therapy post-operatively is costly and access to out-patient IV therapy (OPAT) varies between regions. In a tertiary referral centre for revision and infection, the suitability and cost-effectiveness of Dalbavancin was reviewed as a “single-shot” therapy following DAIR or revision lower limb arthroplasty for PJI. Methods & Materials. A prospective service evaluation was carried out for consecutive patients treated for PJI of the hip or knee who received Dalbavancin. Treatment was indicated by Consultant Microbiologist advice within an MDT setting where clinical or patient factors made alternative therapies eg. OPAT inappropriate. Service-level data was collected to allow calculation of bed-day savings compared to a traditional 14-day course of IV treatment. Readmission rates to the trust within 30 days were reviewed as a marker of clinical efficacy and safety. Results. 12 patients received dalbavancin for PJI. Mean bed-day saving was 6.9 (SD 3.7) per patient. A total of 83 bed days were saved compared to traditional treatment and there was a modest cost-benefit. There were no adverse reactions noted and no readmissions within 30 days. Discussion. The safety and efficacy of dalbavancin has been demonstrated in recent literature, but the impact that it can have on health-care costs and in-patient burden has not been explored. In addition, the success of out-patient therapy relies on patient engagement. In patients with co-existing cognitive difficulty or alcohol/substance use Dalbavancin offers an attractive alternative. Conclusions. The results of our pilot suggest that IV Dalbavancin is cost-effective as part of the treatment strategy for PJI and can lead to significant bed-day savings, which can assist in patient flow and departmental efficiency

Introduction. Pre-operative aspiration and culture is the gold standard for the diagnosis of peri-prosthetic infection. This study aimed to ascertain the diagnostic accuracy of culture of joint aspiration with or without saline re-aspiration in the event of a dry-tap. Patients/Materials & Methods. Retrospective analysis of 343 hip aspirations in patients deemed to have moderate-high risk of infection and ultimately proceeded to revision arthroplasty over 12 years at a large quaternary referral centre where pre-operative aspiration is routine. Results. Fluid was aspirated in 141(41%) cases and dry taps in which saline injection-re-aspiration was performed occurred in 202 (59%) cases. Overall sensitivity and specificity of diagnostic aspirate were 82% (74–88%) and 79% (74–84%) respectively. Sensitivity and specificity of saline injection-re-aspiration after dry tap were 79% (64–87%) and 86% (78–92%) compared to 84% (74–91%) and 74% (66–81%) for direct aspiration. Discussion. Pre-operative joint aspiration and culture is a sensitive and specific test for the confirmation of diagnosis in patients at a moderate to high risk of prosthetic joint infection. Culture of saline injection-re-aspiration also provides accurate diagnostic information in the event of a dry tap. Both methods allow susceptibility testing of relevant organisms and are therefore able to guide peri-operative and cement instilled antibiotic therapy. Conclusions. Culture of pre-operative joint aspirates provides sensitive and specific diagnostic information, including antimicrobial susceptibility results. Saline injection-re-aspiration is a useful additional technique in those patients in whom fluid cannot be aspirated

We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus. The incidence of this infection was 1% over a period of five years. We studied SSI in 15 patients (16 infections) with a mean age of 72.7 years (53 to 81). In all, 12 of the infections occurred early and half of the infections involved the prosthesis, resulting in an increase of 11-fold in the cumulative hospital stay. Methicillin-resistant Staph. aureus was successfully eradicated in all the patients after a mean follow-up of 53.6 months (25 to 88). Superficial incisional infections resolved after antibiotic therapy alone while deep infections required multiple operative debridements. Attempted retention of the implant in early organ space infections was successful in only one of five patients. Only three patients with implant-level infections obtained a pain-free, functional prosthesis while a further three required excision arthroplasty. We have formulated a protocol of treatment which may serve as a guide in the management of these infections

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

No single test is 100% sensitive and specific for the diagnosis of prosthetic joint infection. Joint aspiration is currently the only preoperative investigation that can establish the identity of the infecting organism and its antibiotic susceptibilities. Frequently when attempting to aspirate a joint a ‘dry tap occurs as fluid cannot be aspirated. In this situation, normal saline may be injected into the joint and then reaspirated to provide fluid for culture. The aim of this study was to ascertain the diagnostic accuracy of culture of joint aspiratie with or without saline reaspiration in the event of a dry tap. A retrospective analysis of 580 hip and knee aspirations in patients deemed to have moderate-high risk of infection and ultimately proceeded to revision arthroplasty over 12 years at a large quaternary referral centre where pre operative aspiration is routine. Fluid was aspirated in 313 (54%) cases and dry taps in which saline injection reaspiration was performed occurred in 267 (46%) cases. Overall sensitivity and specificity of diagnostic aspiration were 84% (78–89%) and 85% (81–88%) respectively. Sensitivity and specificity of saline injection-reaspiration after dry tap were 87% (79–82%) and 79% (72–84%) compared to 81% (71–88%) and 90% (85–93%) for direct aspiration. Pre operative joint aspiration and culture is a sensitive and specific test for the confirmation of diagnosis in patients at a moderate to high risk of prosthetic joint infection. Culture of saline injection-reaspiration also provides accurate diagnostic information in the event of a dry tap. Both methods allow susceptibility testing of relevant organisms and are therefore able to guide peri-operative and cement instilled antibiotic therapy. Culture of pre operative joint aspirates provides sensitive and specific diagnostic information including antimicrobial susceptibility results. Saline injection-reaspiration is a useful additional technique in those patients in whom fluid cannot be aspirated

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.

Aims

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

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

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.

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.

A two-stage procedure was carried out on 57 patients with confirmed infection in a hip replacement. Allograft bone was used in the second stage. Pathogenic organisms were identified in all patients. In stage 1, the prosthesis was removed together with infected tissue. Antibiotics were added to customised cement beads. Systemic antibiotics were not used. At the second stage, 45 of the patients had either acetabular impaction grafting, femoral impaction grafting or a combination; 12 had a massive allograft. Eight patients suffered recurrent infection (14%), in six with the original infecting organism. The risk factors for re-infection were multiple previous procedures and highly resistant organisms. We believe that systemic antibiotic therapy should be considered for these patients. Allograft bone is shown to be a useful adjunct in most infected hip replacements with considerable loss of bone stock

Our aim was to determine if the detection rate of infection of total hip replacements could be improved by examining the removed prostheses. Immediate transfer of prostheses to an anaerobic atmosphere, followed by mild ultrasonication to dislodge adherent bacteria, resulted in the culture of quantifiable numbers of bacteria, from 26 of the 120 implants examined. The same bacterial species were cultured by routine microbiological techniques from only five corresponding tissue samples. Tissue removed from 18 of the culture-positive implants was suitable for quantitative tissue pathology and inflammatory cells were present in all samples. Furthermore, inflammatory cells were present in 87% of tissue samples taken from patients whose implants were culture-negative. This suggests that these implants may have been infected by bacteria which were not isolated by the techniques of culture used. The increased detection of bacteria from prostheses by culture has improved postoperative antibiotic therapy and should reduce the need for further revision

Aims

With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases.

Aims

Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique.

Aims

There is a paucity of long-term studies analyzing risk factors for failure after single-stage revision for periprosthetic joint infection (PJI) following total hip arthroplasty (THA). We report the mid- to long-term septic and non-septic failure rate of single-stage revision for PJI after THA.

Aims

We aimed to report the mid- to long-term rates of septic and aseptic failure after two-stage revision surgery for periprosthetic joint infection (PJI) following total hip arthroplasty (THA).