Aim

Periprosthetic joint infection (PJI) is a severe complication after total joint arthroplasty. To prevent PJI, strict infection prevention measures are followed in combination with surgical antibiotic prophylaxis (SAP). To date, scientific reports concerning the optimal duration of SAP in revision arthroplasty are scarce. The aim of this multicenter open-label, randomized controlled trial in the Netherlands, is to investigate the superiority of 5 days (extended) versus a single dose of cefazolin to prevent PJI within the first year after revision arthroplasty of the hip and knee.

Aim

Bone and joint infection requires antimicrobial treatment for 6 to 12 weeks. When patients are well prepared and instructed regarding their therapy, they are more likely to have less side effects and improved compliance. Although side effects are common, this coaching is often not routinely performed when oral treatment is given. We developed a monitoring and guidance program for our outpatients who are on long term antimicrobial therapy, in which we can early signal side effects and treatment failure and coach the patients in their journey of infection treatment.

Aim

In 10% of the presumed aseptic hip or knee revisions, a low-grade infection is unexpectedly diagnosed based on the tissue samples taken during revision. Extended antimicrobial prophylaxis can possibly reduce the failure rate in cases of unexpected PJI, because the prophylaxis can be considered as early empiric treatment. In this randomized controlled study we analysed whether extended antimicrobial prophylaxis compared to a single dose is beneficial to improve the outcome of treatment in unexpected PJI in revision arthroplasty.

Aim

To date, the value of culture results after a debridement, antibiotics and implant retention (DAIR) for early (suspected) prosthetic joint infection (PJI) as risk indicators in terms of prosthesis retention is not clear. At one year follow-up, the relative risk of prosthesis removal was determined for culture-positive and culture-negative DAIRs after primary total hip or knee arthroplasty. The secondary aim was to explore differences in patient characteristics, infection characteristics and outcomes between these two groups.

Aim

Success rate of debridement, antimicrobial and implant retention (DAIR) in high suspicion of early PJI after primary arthroplasty is 70–80%. No studies have been performed focusing on outcome of DAIR after revision arthroplasty of the hip (THA) or knee (TKA). The aim of this study is to investigate the outcome of DAIR in suspected early PJI after revision THA or TKA and to identify risk factors for failure.

Aim

Periprosthetic joint infection (PJI) is a feared complication of total joint arthroplasty of hip (THA) or knee (TKA). Debridement, antibiotic treatment, and implant retention (DAIR) is an effective treatment of early PJI. In the Netherlands, cefazolin resistance in early PJI after primary arthroplasty is low. Little is known about causative micro-organisms and resistance patterns in PJI after revision arthroplasty. No recommendations for empirical treatment are described in the current guidelines. The aim of this study is to describe the characteristics of PJI after revision arthroplasty and to evaluate whether the used empirical treatment regimens are adequate, based on microbiology data.

Aim

National Joint Replacement Registries, which are important sources for periprosthetic joint infection (PJI) data, report an average PJI incidence ranging from 0.5 to 2.0%. Unfortunately, national registries including the Dutch Arthroplasty Register (LROI), are not specifically designed to register PJI. In the Netherlands, the LROI is a nationwide population-based registry with an overall completeness of more than 95%.³ To ensure usability and reliability of PJI data from the LROI, it is important to evaluate the quality and completeness of these data. From 2013 onwards, eight hospitals in the South-East of the Netherlands, collected their PJI data in a detailed regional infection cohort (RIC), specifically designed for this purpose. This study aimed to determine the accuracy and completeness of PJI registration (hip and knee arthroplasty) in the LROI, by comparing the LROI with the RIC.

We designed a study to evaluate whether (1) there were differences in PROMs between different reasons for revision THA at baseline, (2) there was a different interaction effect for revision THA for all PROMs, and (3) complication and re-revision rates differ between reason for revision THA.

Prospective cohort of 647 patients undergoing rTHA, with a minimum of 2 years FU. The reason for revision were classified as infection, aseptic loosening, dislocation, structural failure and painful THA with uncommon causes. PROMs (EQ-5D score, Oxford hip score (OHS), VAS pain, complication and failure rates were compared between different groups.

Patients with different reason for revision had improvement of PROMs’ over time. Preoperatively, patients revised due to infection and aseptic loosening had poorer OHS and EQ-5D than patients with other reason for revision. Pain scores at baseline were highest in patients revised due to dislocation. Infection and aseptic loosening groups also showed a significant interaction effect over time in both OHS and EQ-5D. No PROMs significant differences between groups were observed 2 years postoperatively. Overall complications, and re-revision rates were 35.4 and 9.7% respectively.

The reason for revision THA did not associate with clinical outcomes. Good outcomes were reached regardless of the reason for revision, as patients with the poorest pre-operative scores had the best improvement in PROMs over time. Complication and re-operation rates were relatively high, in line with previous reports, but did not differ between different reasons for revision THA.

Ruling out an infection in one-stage knee and hip revisions for presumed aseptic failure by conventional tissue cultures takes up to 14 days. Multiplex polymerase chain reaction (PCR) is a quick test (4–5 hours) for detecting infections. The purpose of this study was to evaluate the negative predictive value of an automated multiplex PCR for the detection of microorganisms in synovial fluid obtained intraoperatively in unsuspected knee and hip revisions.

The NPV of the multiplex PCR U-ITI system of synovial fluid compared to tissue cultures of knee and hip revisions was 95.7% and 92.5%, respectively. Cultures required several days for growth whereas the automated mPCR U-ITI system provided results within five hours.

The multiplex PCR U-ITI system is a quick and reliable test in ruling out infection in presumed aseptic knee and hip revisions. With this test the number of unsuspected infected revisions can be lowered and antibiotic overtreatment as well as undertreatment after one-stage revision arthroplasty can be avoided. This directly results in a reduction in length of hospital stay, hospital costs and possible antibiotic resistance development.

Aim

Long term use of antibiotics following surgical debridement are the cornerstone of PJI treatment. Due to increasing resistance of bacteria for many first line antibiotics new options are needed. One such option is linezolid known for its low percentage of resistance against many Gram positive bacteria causing PJI. Success rates up to 86% have been reported. At the same time many adverse events (AE) have been described including anemia, thrombocytopenia, gastrointestinal effects and sometimes neuropathy, e.g. irreversible vision loss [1, 2]. Therefore, linezolid use is advised to be limited to a maximum of 28 days. Literature about the effects of prolonged use is currently lacking and therefore this study will aim to determine the safety of long-term (>28 days) linezolid use in patients with orthopedic infections.

Aim

Currently, despite a thorough diagnostic work up, around ten percent of the presumed aseptic revisions turn out to have unexpected positive cultures during the revision procedure. The purpose of this study was to evaluate the negative predictive value (ruling out) of the automated multiplex PCR Unyvero i60 implant and tissue infection (ITI) cartridge (U-ITI) system for the detection of microorganisms in synovial fluid obtained intraoperatively.

Aim

Prosthetic Joint Infection (PJI) remains one of the leading cause for revision arthroplasty.^1,2 Early recognition and appropriate initial treatment of early PJI with debridement, antibiotics and implant retention (DAIR) can eradicate infection on first attempt and prevent implant failure. We evaluated the outcome after one year of patients who were treated for an early PJI after primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) with DAIR. Furthermore, we determined preoperative infection markers, microbiology, and treatment factors related to treatment failure after DAIR procedure.

Aim

Despite a preoperative workup with no evidence to suspect a prosthetic joint infection (PJI) before revision surgery, routinely obtained intraoperative cultures still can be unexpectedly positive. The purpose of this study was (1) to assess the incidence of unexpected positive intraoperative cultures in presumed aseptic knee and hip revisions and (2) to determine whether a difference exists between the infection-free implant survival rate of patients with and without unexpected positive intraoperative cultures.

Prosthetic joint infections (PJI) caused by Streptococcus species are relatively common.

The aim of our study was to assess outcome after treatment for early and late PJI with Streptococcus species after a follow-up of two years.

For this study we retrospectively included all patients with primary or revision total knee arthroplasty (TKA) or total hip (THA) arthroplasty, a minimum of two periprosthetic tissue cultures positive for Streptococcus species and a minimum follow-up of one year. According to international guidelines patients were classified as having early or late PJI. All patients with an early PJI were treated according to a standard treatment protocol, i.e. debridement and retention of the prosthesis, followed by adequate antibiotic therapy. Patients with late PJI underwent a debridement followed by adequate antibiotic therapy or joint revision. Patients’ hospital records were reviewed and we evaluated the status of the original prosthesis after an infection.

Forty cases were included; 24 early and 16 late PJI. For early PJI, open debridement was performed in all patients, after a mean of 19 (range: 9 – 80) days. At final follow-up 21 prostheses (88%) were still in situ and without clinical signs of infection. Eight cases (41%) of late PJI were successfully treated with debridement and retention. Nine patients (59%) underwent a one- or two-stage revision. At final follow-up 16 patients (100%) with late PJI had a prosthesis in situ. Streptococcus dysgalactiae species accounted for more than 50% of the early infections, followed by Streptococcus agalactiae with 30%.

In case of PJI with Streptococcus species open debridement and retention of the prosthesis should be performed followed by adequate and long-term antibiotic treatment. As expected, the retention rate for early PJI is much higher than that for late PJI.

Background: In order to achieve a minimized need for tissue dissection resulting in a faster rehabilitation, minimally invasive surgery (MIS) in Total Hip Arthroplasty (THA) was developed. In this small incision technique the skin and musle dissection has been reduced with respect to the classical approach. Literature shows ambiguous results comparing the posterolateral minimally incisive with the classical approach. As the anterolateral approach is also a routine procedure, and to test how minimally invasive MIS is, we hypothesized that patients treated with a THA using a posterolateral or anterolateral MIS would experience improved clinical results compared with a standard incision after six weeks and no clinical differences after one year. This was tested in a double-blind randomized controlled trial with the Harris Hip Score (HHS) as a primary endpoint.

Methods: One hundred and twenty consecutive primary uncemented THAs were randomized into one of four groups of 30 patients each. Either standard posterolateral or anterolateral approaches (PL- or AL-CLASS), or minimal invasive posterolateral or anterolateral approaches (PL- or AL-MIS) were performed. CLASS incisions were 18 cm. To avoid postoperative bias, MIS incisions were extended at skin level to 18 cm at the end of the procedure. The HHS as well as patient-centered questionnaires (SF-36, WOMAC and OHS) was obtained preoperatively, at six weeks and one year after the index operation. Preoperative data, blood loss, hemoglobin, muscle damage parameters and radiological parameters were analyzed. In order to detect a minimal clinically important difference of five points or more between the MIS or CLASS groups with respect to the Harris Hip Score at the 0.05 alpha level with 80% power, 120 patients were enrolled in the study.

Results: Mean incision length of the THAs performed by MIS was 7.8 (SD = 1.6). In the patients of the MIS group a significant increased mean HHS was observed compared with the CLASS (p = 0.03) after six weeks and one year. This difference was caused by the favorable results of the PL-MIS (p = 0.009). Of the three patient-centered questionnaires, the SF-36 results were also favourable in the PL-MIS group after six weeks (p = 0.04). In the MIS group operation time was longer (p < 0.001) and a learning curve was observed based on operation time and complication rate. Peri-operative complications rates were not significantly different between the groups. Blood loss, hemoglobin, muscle damage parameters and radiological parameters also showed no difference.

Conclusions: This double-blind, randomized study reveals an improved clinical outcome of the PL-MIS compared with the AL-MIS, PL-CLASS and AL-CLASS after six weeks and one year follow-up with the Harris Hip Score as primary endpoint.

Background: The purpose of this systematic review was to determine the clinical and radiologic benefit of hydroxyapatite-coating in uncemented primary total hip arthroplasty.

Methods: A database of Medline articles published up to september 2007 was compiled and relevant references screened. Studies that satisfied the following selection criteria were included:

a proper randomized controlled trial;

Results: Eight studies, involving 857 patients, were included in the review. Observer agreement was 94%, while the interobserver reliability was K =.799 (.611 −.987); P < 0.001. Pooled analysis for Harris Hip Score as a clinical outcome measure demonstated no advantage of the hydroxyapatite coating (WMD: 1.49, CI: −2.32 to 5.31, P = 0.44). Radiologically, both groups showed equal presence of endosteal bone ingrowth (RR: 1.04, CI: 0.88 to 1.23, P = 0.66) and radio-active lines (RR: 1.02, CI: 0.90 to 1.16, P = 0.74) in the surface area of the prosthesis. Pooling on stem subsidence was not feasible, because three different measurement techniques were used.

Conclusion: Based on eight randomized controlled trials, this meta-analysis demonstrates no clinical nor radiological benefits to the application of a hydroxy-apatite coating on a femoral component in uncemented primary total hip arthroplasty.