Aim

There is limited data on the frequency and impact of untoward events such as glove perforation, contamination of the surgical field (drape perforation, laceration, detachment), the unsterile object in the surgical field (hair, sweat droplet…), defecation, elevated air temperature…that may happen in the operating theatre. These events should influence the surgical site infection rate but it is not clear to what extent. We wanted to calculate the frequency and measure the impact of these events on the infection and general revision rate.

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We investigated the rates of revision surgery for the treatment of PJI following primary and revision hip and knee replacement, explored time trends, and estimated the overall surgical burden created by PJI. We analysed the National Joint Registry for England and Wales for revision hip and knee replacements performed for a diagnosis of PJI and their index procedures from 2003–2014. The index hip replacements consisted of 623,253 primary and 63,222 aseptic revision hip replacements with 7,642 revisions subsequently performed for PJI; for knee replacements the figures were 679,010 primary and 33,920 aseptic revision knee replacements with 8,031 revisions subsequently performed for PJI. Cumulative incidence functions, prevalence rates and the burden of PJI in terms of total procedures performed as a result of PJI were calculated. Revision rates for PJI equated to 43 out of every 10,000 primary hip replacements (2,705/623,253), i.e. 0.43%(95%CI 0.42–0.45), subsequently being revised due to PJI. Around 158 out of every 10,000 aseptic revision hip replacements performed were subsequently revised for PJI (997/63,222), i.e. 1.58%(1.48–1.67). For knees, the respective rates were 0.54%(0.52–0.56) for primary replacements, i.e. 54 out of every 10,000 primary replacements performed (3,659/679,010) and 2.11%(1.96–2.23) for aseptic revision replacements, i.e. 211 out of every 10,000 aseptic revision replacements performed (717/33,920). Between 2005 and 2013, the risk of revision for PJI in the 3 months following primary hip replacement rose by 2.29 fold (1.28–4.08) and after aseptic revision by 3.00 fold (1.06–8.51); for knees, it rose by 2.46 fold (1.15–5.25) after primary replacement and 7.47 fold (1.00–56.12) after aseptic revision. The rates of revision for PJI performed at any time beyond 3 months from the index surgery remained stable or decreased over time. From a patient perspective, after accounting for the competing risk of revision for an aseptic indication and death, the 10-year cumulative incidence of revision hip replacement for PJI was 0.62%(95%CI 0.59–0.65) following primary and 2.25%(2.08–2.43) following aseptic revision; for knees, the figures were 0.75%(0.72–0.78) following primary replacement and 3.13%(2.81–3.49) following aseptic revision. At a health service level, the absolute number of procedures performed as a consequence of hip PJI increased from 387 in 2005 to 1,013 in 2014, i.e. a relative increase of 2.6 fold. While 70% of those revisions were two-stage, the use of single stage revision increased from 17.6% in 2005 to 38.5% in 2014. For knees, the burden of PJI increased by 2.8 fold between 2005 and 2014. Overall, 74% of revisions were two-stage with an increase in use of single stage from 10.0% in 2005 to 29.0% in 2014. Although the risk of revision due to PJI following hip or knee replacement is low, it is rising. Given the burden and costs associated with performing revision joint replacement for prosthetic joint infection and the predicted increased incidence of both primary and revision hip replacement, this has substantial implications for service delivery

Periprosthetic joint infections (PJI) continue to be a diagnostic challenge for orthopedic surgeons. Chronic PJI are sometimes difficult to diagnose and occasionally present in a subclinical fashion with normal CRP/ESR and/or normal joint aspiration. Some institutions advocate for routine use of intraoperative culture swabs at the time of all revision surgeries to definitively rule out infection. The purpose of this study is to determine whether routine intraoperative cultures is an appropriate and cost effective method of diagnosing subclinical chronic PJI in revision joint replacement patients with a low clinical suspicion for infection. We performed a retrospective chart review and identified 33 patients that underwent revision hip or knee replacement from a single surgeon over a five-month period. The AAOS guidelines for preoperative PJI workup were followed. 13 patients were diagnosed preoperatively with infection and excluded from the study. 20 patients underwent revision joint replacement and three separate cultures swabs were taken for each patient to help in determining true-positive cultures. Infectious Disease was consulted for all patients with any positive culture. Culture results were reviewed. At our hospital, the cost billed to insurance for a single culture is $1,458.58. We did not calculate the cost of the consultant fee. Three (15%) of the 20 revision arthroplasty patients had a single positive culture. Infectious Disease consultants diagnosed all three of these positive cultures as contaminants. None of the patients had a true-positive intraoperative culture. The total cost billed by the hospital to obtain these cultures in all 20 patients was $87,514.80. In our study, obtaining a set of three intraoperative cultures for those patients with a negative preoperative infection workup was not only cost prohibitive but did not diagnose a single subclinical infection. Studies to find other more reliable, accurate, and cost effective alternatives to diagnose PJI are warranted. In patients undergoing revision hip or knee arthroplasty with a low preoperative clinical suspicion for infection, it does not seem that routine intraoperative culture swabs are necessary or cost effective method for diagnosing subclinical periprosthetic joint infection

Aims

This study aimed to compare the effect of antibiotic-loaded bone cement (ALBC) versus plain bone cement (PBC) on revision rates for periprosthetic joint infection (PJI) and all-cause revisions following primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Introduction. Infection after total joint arthroplasty is a challenging problem. Clinical symptoms, Erythrocyte sedimentation rate, C-reactive protein level, and cultures of synovial fluid obtained by means of percutaneous aspiration are commonly used to rule out the possibility of persistent infection before reimplantation. However, the sensitivity and specificity of the tests are low. Some authors have suggested that frozen-section analysis should always be performed during the reimplantation in order to rule out persistent infection. Methods. Retrospective review of 126 revision hip and knee arthroplasty procedure performed from 2002 - 2007 in Derriford Hospital, Plymouth NHS truts, UK. Frozen section was performed in 86 procedures out of the 126 procedures reviewed(68.2 %). A positive frozen section with more than 10 PNLs per HPF was compared with intra operative cultures results. The preoperative CRP results were recorded as well. Results. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for frozen section were 45.5 %, 93.1%,50%, 95%, 94% respectively. Combining the intraoperative frozen section with the CRP results, the specificity was 100%. Discussion. A negative finding on intra operative analysis of frozen sections has a high predictive value with regard to ruling out the presence of infection; However, the sensitivity of the test for the detection of persistent infection is low. The data support the conclusion that the Frozen Section is reasonably specific but not a sensitive. Combining it with the preoperative CRP results led to increasing the specificity to 100% in our series

Aim

”There is not a lot of data of the frequency and impact of unwanted events including glove perforation, contamination of the surgical field (drape perforation, laceration, detachment, bone bounced back from an unsterile object), unsterile object in the surgical field (hair, sweat droplet…), defecation, elevated air temperature, and others. Mishaps occur in every surgical theatre. These events should influence the surgical site infection rate but it is not clear to what extent. We wanted to calculate the frequency and measure the impact of these events on the infection and revision rate of the relative patients.”

Peri-prosthetic fracture after joint replacement in the lower limb is associated with significant morbidity. The primary aim of this study was to investigate the incidence of peri-prosthetic fracture after total hip replacement (THR) and total knee replacement (TKR) over a ten-year period using a population-based linked dataset.

Between 1 April 1997 and 31 March 2008, 52 136 primary THRs, 8726 revision THRs, 44 511 primary TKRs, and 3222 revision TKRs were performed. Five years post-operatively, the rate of fracture was 0.9% after primary THR, 4.2% after revision THR, 0.6% after primary TKR and 1.7% after revision TKR. Comparison of survival analysis for all primary and revision arthroplasties showed peri-prosthetic fractures were more likely in females, patients aged > 70 and after revision arthroplasty.

Female patients aged > 70 should be warned of a significantly increased risk of peri-prosthetic fracture after hip or knee replacement. The use of adjuvant medical treatment to reduce the effect of peri-prosthetic osteoporosis may be a direction of research for these patients.

Aims. The aim of this study was to conduct evidence synthesis on the available published literature of the impact of the training status of the operating surgeon (trainee vs. consultant) on the survival and revision rate of primary hip and knee replacements. Patients and Methods. We conducted a systematic review according to Cochrane guidelines. Separate searches were performed for hip and knee replacements, with meta-analysis and presentation of results in parallel. We searched MEDLINE and Embase databases from inception to 17 September 2019 and included controlled trials and cohort studies reporting implant survival estimates, or revision rates of hip and knee replacements according to the grade of the operating surgeon. This study was registered with PROSPERO (CRD42019150494). Results. 8 studies (5 hip papers and 3 knee papers) met the inclusion criteria. There was no significant difference in the survival estimates for total hip replacements (THRs) performed by trainees compared to consultants at 5-years follow-up (97.9% vs 98.1%, p = 0.74). Furthermore, there was no significant difference in the revision rate of THRs performed by trainees and consultants at both 5 and 10-year intervals of follow-up (relative risk [RR]: 5yrs = 0.88 (95% CI: 0.46, 1.70; P = 0.71); 10yrs = 0.68 (95% CI: 0.37, 1.26; P = 0.22)). There was no significant difference in the survival estimates at 10-years for total knee replacements (TKRs) performed by trainees compared to consultants (96.2% vs 95.1%, p=0.49). Conclusion. There is no evidence in the existing literature that trainee surgeons have worse outcomes than their consultant colleagues, in terms of the survival, or rate of revision of hip and knee replacements at 5–10 years follow-up. This may mean that there is genuinely no difference or that, in the context of contemporary training programmes, appropriate case-mix selection and supervision of trainees is currently employed

With an ageing population and an increasing number of primary arthroplasties performed, the revision burden is predicted to increase. The aims of this study were to 1. Determine the revision burden in an academic hospital over a 11-year period; 2. identify the direct hospital cost associated with the delivery of revision service and 3. ascertain factors associated with increased cost. This is an IRB-approved, retrospective, single tertiary referral center, consecutive case series. Using the hospital data warehouse, all patients that underwent revision hip or knee arthroplasty surgery between 2008-2018 were identified. 1632 revisions were identified (1304 patients), consisting of 1061 hip and 571 knee revisions. The majority of revisions were performed for mechanical-related problems and aseptic loosening (n=903; 55.3%); followed by periprosthetic joint infection (n=553; 33.9%) and periprosthetic fractures (176; 10.8%). Cost and length of stay was determined for all patient. The direct in-hospital costs were converted to 2020 inflation-adjusted Canadian dollars. Several patients- (age; gender; HOMR- and ASA-scores; Hemoglobin level) and surgical- (indication for surgery; surgical site) factors were tested for possible associations. The number of revisions increased by 210% in the study period (2008 vs. 2018: 83 vs. 174). Revision indications changed over study period; with prevalence of fracture increasing by 460% (5 in 2008 vs. 23 in 2018) with an accompanying reduction in mechanical-related reasons, whilst revisions for infection remained constant. The mean annual cost over the entire study period was 3.9 MMCAD (range:2.4–5.1 MMCAD). The cost raised 150% over the study period from 2.4 MMCAD in 2008 to 3.6 MMCAD. Revisions for fractured had the greatest length of stay, the highest mean age, HOMR-score, ASA and cost associated with treatment compared to other revision indications (p < 0 .001). Patient factors associated with cost and length of stay included ASA- and HOMR-scores, Charlson-Comorbidity score and age. The revision burden increased 1.5-fold over the years and so has the direct cost of care delivery. The increased cost is primarily related to the prolonged hospital stay and increased surgical cost. For tertiary care units, these findings indicate a need to identify strategies on improving efficiencies whilst improving the quality of patient care (e.g. efficient ways of reducing acute hospital stay) and reducing the raise of the economic burden on a publicly funded health system

Two stage revision for infection is considered the gold standard with a success rate of 80–90%. Overall functional outcomes of these patients are commonly overlooked. There is a trend towards single stage revision to improve functional outcomes.

We examined the functional scores of 2 stage revision for total hip arthroplasty (THR) and total knee arthroplasty (TKR). 72 revisions were identified over 9 years: 30 THR and 42 TKR. Two year survivorship was 96% in THR revision and 88% TKR revision. Five year survival was 83% and 84% respectively. 50 patients (without recurrence of infection) had recorded functional scores at a minimum of 1 year.

The mean Harris-hip score (HHS) of THR was 75 (21 patients) prior to developing symptoms of infection. Once infected, the mean score fell to 46. At 1 year post revision it returned to 77. At 3 years HHS of 78 (12 patients) and at 5 yrs 62 (3 patients).

The mean knee society score (KSS) of TKR was 66 (29 patients) prior to developing symptoms of infection. Once infected, the mean score fell to 34. At 1 year post revision it returned to 73. At 3 years KSS of 76 (16 patients) and at 5 years 62 (10 patients).

We conclude that functional scores of staged revisions of infected THR and TKR return to pre-morbid levels within a year of completing the second stage. Although single stage revision may have a quicker return to function, by 1 year, staged revision has comparable results.

Aims. The purpose of this study is to determine if higher volume hospitals have lower costs in revision hip and knee arthroplasty. Materials and Methods. We questioned the Centres for Medicare and Medicaid Services (CMS) Inpatient Charge Data and identified 789 hospitals performing a total of 29 580 revision arthroplasties in 2014. Centres were dichotomised into high-volume (performing over 50 revision cases per year) and low-volume. Mean total hospital-specific charges and inpatient payments were obtained from the database and stratified based on Diagnosis Related Group (DRG) codes. Patient satisfaction scores were obtained from the multiyear CMS Hospital Compare database. Results. High-volume hospitals comprised 178 (30%) of the total but performed 15 068 (51%) of all revision cases, including 509 of 522 (98%) of the most complex DRG 466 cases. While high-volume hospitals had higher Medicare inpatient payments for DRG 467 ($21 458 versus $20 632, p = 0.038) and DRG 468 ($17 003 versus $16 120, p = 0.011), there was no difference in hospital specific charges between the groups. Higher-volume facilities had a better CMS hospital star rating (3.63 versus 3.35, p < 0.001). When controlling for hospital geographic and demographic factors, high-volume revision hospitals are less likely to be in the upper quartile of inpatient Medicare costs for DRG 467 (odds ratio (OR) 0.593, 95% confidence intervals (CI) 0.374 to 0.941, p = 0.026) and DRG 468 (OR 0.451, 95% CI 0.297 to 0.687, p <  0.001). Conclusion. While a high-volume hospital is less likely to be a high cost outlier, the higher mean Medicare reimbursements at these facilities may be due to increased case complexity. Further study should focus on measures for cost savings in revision total joint arthroplasties. Cite this article: Bone Joint J 2017;99-B:1611–17

Purpose. To establish the reliability of reporting and recording revision hip and knee arthroplasties by comparing data in the National Joint Registry (NJR), Hospital Episode Statistics (HES) and our local theatre records. Methods. The paper theatre registers for all orthopaedic theatres in the Royal Derby Hospitals NHS Trust were examined for details of revision hip and knee replacements carried out in 2007 and 2008. This was then cross-checked and merged with the local electronic theatre data to obtain a definitive local record of all revision hip and knee arthroplasties. Data for the same period was requested from the NJR and HES and these data were checked against our definitive local record for discrepancies. The HES codes used were the same codes used to compile the recent NJR annual reports. Results. The theatre registers and ORMIS identified 271 revision hip and knee arthroplasties in the study period. The NJR had corresponding data for 176 (65%) of these, and HES had 250 (92%). 10 cases (4%) were not recorded by either NJR or HES: 8 secondary resurfacings of patellae and 2 posterior lip augmentations in hips. Of those operations “missed” by HES, most had been assigned a correct “W” code, but had a “Y” or “Z” OPCS code not used in the NJR annual reports. Conclusion. When HES and the NJR data are combined, they are an accurate representation of real practice. More robust methods of reporting revision arthroplasty to the NJR are required. The OPCS codes used to indicate a revision need to be reviewed

Aims

The outcomes of patients with unexpected positive cultures (UPCs) during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. The objectives of this study were to establish the prevalence and infection-free implant survival in UPCs during presumed aseptic single-stage revision THA and TKA at mid-term follow-up.

Introduction

A proportion of patients with hip and knee prosthetic joint infection (PJI) undergo multiple revisions with the aim of eradicating infection and improving quality of life. The aim of this study was to describe the microbiology cultured from multiply revised hip and knee replacement procedures to guide antimicrobial therapy at the time of surgery.

Aims

Nonagenarians (aged 90 to 99 years) have experienced the fastest percent decile population growth in the USA recently, with a consequent increase in the prevalence of nonagenarians living with joint arthroplasties. As such, the number of revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in nonagenarians is expected to increase. We aimed to determine the mortality rate, implant survivorship, and complications of nonagenarians undergoing aseptic revision THAs and revision TKAs.

Aims

The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without.

To ascertain whether there is any relationship between the Oxford 12 scores gained six months post surgery and early revision for primary hip and knee arthroplasty. The six month post surgery Oxford 12 scores were retrieved from the National Joint Registry (NJR) for the seven year period ending 31. st. December 2006. These were analysed in relation to revision of primary hip and knee procedures using three methods of statistical analysis; logistic regression, receiver operating characteristic (ROC) curve and direct plotting of groups of scores against the proportion of hips revised for that same group. Logistic regression: For every one unit increase in the Oxford score there was an 11% increased risk of revision (hips) and 12% (knees) within the first two years of surgery, 5 and 6% respectively between two and four years and 3 and 4% risk respectively between four and six years (p> 0.001). The ROC Curve Analysis: demonstrated that a patient with a score greater than 20 (hips) or 28.5 (knees) or 24 (uni knees) has eight times the risk of needing a revision within two years compared to a person with a score equal or less than the above numbers. Alternatively the ROC analysis predicted 73% of the revisions within three years for all three arthroplasty groups. Plotting Scores Against Revisions: Plotting scores in groups of five demonstrated an incremental increase in the risk during the first two years. A person with a score greater than 40 has; for hips 24 times, knees 27 times and uni knees 69 times the risk of a revision within two years compared to a person with a score between 16 and 20. Monitoring of the six month post surgical Oxford 12 score is another tool in the surgeon’s armamentarium for deciding which patients need closer monitoring following arthroplasty surgery

Abstract

Aims. The aim of this study was to determine if a three-month course of microorganism-directed oral antibiotics reduces the rate of failure due to further infection following two-stage revision for chronic prosthetic joint infection (PJI) of the hip and knee. Methods. A total of 185 patients undergoing a two-stage revision in seven different centres were prospectively enrolled. Of these patients, 93 were randomized to receive microorganism-directed oral antibiotics for three months following reimplantation; 88 were randomized to receive no antibiotics, and four were withdrawn before randomization. Of the 181 randomized patients, 28 were lost to follow-up, six died before two years follow-up, and five with culture negative infections were excluded. The remaining 142 patients were followed for a mean of 3.3 years (2.0 to 7.6) with failure due to a further infection as the primary endpoint. Patients who were treated with antibiotics were also assessed for their adherence to the medication regime and for side effects to antibiotics. Results. Nine of 72 patients (12.5%) who received antibiotics failed due to further infection compared with 20 of 70 patients (28.6%) who did not receive antibiotics (p = 0.012). Five patients (6.9%) in the treatment group experienced adverse effects related to the administered antibiotics severe enough to warrant discontinuation. Conclusion. This multicentre randomized controlled trial showed that a three-month course of microorganism-directed, oral antibiotics significantly reduced the rate of failure due to further infection following a two-stage revision of total hip or knee arthroplasty for chronic PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):3–9