Aim

Predicting success of a Debridement, Antibiotics and Implant Retention (DAIR) procedure for Periprosthetic Joint Infection (PJI) remains a challenge. A failed DAIR might adversely affect the outcome of any future revision surgery for PJI. Hence, the ability to identify and optimise factors predictive of DAIR success would help target the procedure to the appropriate patient cohort and avoid unnecessary surgery for patients where a DAIR is unlikely to eradicate infection.

The benefits of cell salvage autotransfusion are well reported. There is a common non-evidenced belief amongst revision arthroplasty surgeons that auto-transfusion is potentially contraindicated in infected revisions.

The aim is to study the immediate and delayed outcomes of using cell saver on patients undergoing PJI surgery.

Prospective cohort service evaluation registered with the local audit department. 20 PJI cases in 18 patients where cell saver was used over a period of 4 years. Intraoperative fluid and tissue samples were taken for culture. Blood culture from salvaged blood pre and post leucodepletion filter were sent for microbiological analysis. Data on type of surgery, blood loss, further allogenic transfusion and SIRS response was collected. Success of infection clearance was assessed using 2019 MSIS ORT. Five patients receiving autologous blood in non-infection cases were used as controls.

Mean age for the PJI group was 67.7 years, 67% female. 11 patients (67%) had 1st stage surgery and 5 (25%) underwent 2nd stage whereas 4 patients had single stage surgery. The mean calculated blood loss was 1398 mls (range 400–3000mls). 6 Patients required further allogenic transfusion. 16 patients received blood via a leuco-depletion filter. The same organism grown from tissues was identified in post-filter blood in 8/17 patients (47%).

2/20 have grown a different organism in post-filtered blood, _P.Acne._

2 patients developed SIRS upon auto-transfusion, however one was thought to be secondary to cementing. The control group had 443 mls mean amount of blood loss and 1 patient developed a SIRS response.

14/20 (70%) patients had successful clearance of infection (tier 1) 2 patients died prior to undergoing 2nd stage.

Using cell saver did not impact main outcome of infection clearance in PJI surgery. We would advocate its routine usage whilst avoiding direct collection of heavily contaminated blood.

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

Aim

The duration of systemic antibiotic therapy following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, use high concentration targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy in the management of PJI of the hip using our two-stage protocol.

The duration of systemic antibiotics following first-stage surgery is contentious. Our Institution's philosophy is to perform an aggressive debridement, high concentration of targeted antibiotics through cement beads and systemic prophylactic antibiotics alone. In the presence of significant soft tissue infection or microbiological diagnostic uncertainty; systemic antibiotics may be prescribed for 5 days whilst awaiting tissue culture results. The aim of this study was to assess the success of our philosophy for two-stage hip revision.

A retrospective review of our Institution's prospective database was performed to identify all intended two-stage hip revision procedures for PJI. All patients had a confirmed PJI as per MSIS 2013 criteria, minimum 5-years follow up and outcomes according to the MSIS working group outcome-reporting tool; then grouped into “successful” or “unsuccessful” (suppressive antibiotics, further revision for infection, death within 1 year).

383 intended two-stage hip revisions were identified; of which 299 met our inclusion criteria, in 289 patients (6 repeat ipsilateral two-stage, 4 bilateral two-stage). Median follow up was 10.7 years (IQR 6.3 – 15.0). 258 (86%) patients proceeded to 2^nd stage surgery. 91% success rate was observed for those patients who underwent reimplantation, although dropping to 86% when including the patients who did not proceed to second stage. The median duration of post-operative systemic antibiotics was 5 days (IQR 5–9). No significant difference was observed in patients who received either; < / = 48 hours (86%; n=70) compared to > 48 hours antibiotics (86%; n=229; p=0.96) or </= 5 days of antibiotics (88%; n=202) compared to > 5 days antibiotics (82%; p=0.38). A significant majority had gram-positive (88%) infection with 30% being polymicrobial. Greater success rates were observed with two-stage exchange or gram-positive PJI (86%); than for gram-negative PJI (81%) and polymicrobial infection (74%) (p=0.36). Fungal PJI was observed to have a significantly reduced rate of success (n=3; 33%; p=0.03).

Aggressive surgical debridement with high concentration, targeted local antibiotic delivery at time of first stage to manage PJI of the hip provides a high rate of success, responsible antibiotic stewardship and reduced hospital costs.

Revision total hip arthroplasty (rTHA) can be complex and associated with significant cost, with an increasing burden within the UK and globally. Regional rTHA networks have been proposed aiming to improve outcomes, reduce re-revisions and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for the rTHA service and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

A retrospective analysis of all revision hip procedures was performed over two consecutive financial years (2018–2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and by mode of failure; infected or non-infected. Patients of ASA grade of 3 or greater or BMI over 40 are considered “high-risk” by the RHCC. Costs were calculated using PLICS and remuneration based on the HRG data. The primary outcome was the financial difference between tariff and cost per episode per patient. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test.

199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1), 110 (55%) complex revisions (H2) and 64 (32%) most complex revisions (H3). 76 (38%) cases were due to infection. 78 (39%) of patients were in the “high-risk” group. Median length of stay increased with case complexity from 4, to 6 to 8 days (p=0.17) and significantly for revisions performed for infection (9 vs 5 days; p=0.01). Cost per episode increased significantly between complexity groups (p=0.0002) and for infected revisions (p=0.003). All groups demonstrated a mean deficit, but this significantly increased with revision complexity (£301, £1,820 and £4,757 per case; p=0.02) and for infected failure (£4,023 vs £1,679; p=0.02). The total deficit to the trust for the two-years was £512,202.

Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHA at major revision centres (MRC) will likely place a greater financial burden on these units.

Background

An extended trochanteric osteotomy (ETO) is a widely used approach for revision hip arthroplasty. Following an ETO it is common practice to use a long stemmed femoral prosthesis at the second stage to bypass the osteotomy. We propose that at the second stage, if the osteotomy has united, it is appropriate to use a standard length prosthesis, which preserves bone stock for any future revisions.

Background: Diagnostic injection plays an increasing role in the diagnosis of foot and ankle pathology. Joint communications have been reported in several studies, and it has been suggested they may impact on clinical management.

Method: We analysed the findings of 389 arthrograms of the foot and ankle, identifying any joint communications noted on imaging. A case note review was then undertaken on a subset of 153 of these patients with the aim of establishing the effect of injection findings on clinical management. All injections were performed and reported by a single consultant radiologist.

Results: Joint communications were seen in 24% of patients with an equal distribution amongst males and females. Rates of individual joint communications were consistent with those previously published.

Injection studies had an impact on subsequent management in 88% of cases. Symptoms resolved with injection alone in 28% of patients with no communication versus 8% in those with a communication. Surgical plans were changed in over 20% of cases if a joint communication was found. There were no major complications reported (Joint sepsis or contrast allergy).

Conclusion: This study confirms the presence of multiple joint communications within the foot and ankle, and highlights the importance of arthrography in the diagnosis of pathology.

We would recommend joint injection be considered in all patients, especially if joint fusion is being considered. Contrast should be used in all cases to demonstrate any potential communications, which should be taken into consideration when surgical management plans are formulated. A significant number of patients will experience resolution of symptoms from injection alone, with no further intervention needed.