Orthopedic surgeons have relied heavily on opiates after total hip replacement (THR) despite no clear evidence of benefit and a rapidly growing abuse epidemic. Multimodal analgesia may reduce or even obviate the need for opiates after elective surgery. In a cluster-randomized, crossover trial, 235 patients undergoing THR were assigned to receive multimodal analgesia with minimal opiates (Group A-10 tablets), multimodal analgesia with a full opiate supply (Group B-60 tablets), or a traditional opiate regimen without multimodal analgesia (Group C-60 tablets). The multimodal regimen comprised scheduled-dose acetaminophen, meloxicam, and gabapentin. Primary outcomes were daily pain and opiate utilization for the first 30-days. Secondary outcomes included assessments of satisfaction, sleep-quality, opiate-related symptoms, hip function, and adverse events.Background
Methods
Next-generation sequencing (NGS) is a well-established technique for amplification and sequencing of DNA and has recently gained much attention in many fields of medicine. Our aim was to evaluate the ability of NGS in identifying the causative organism(s) in patients with periprosthetic joint infection (PJI). In this prospective study samples were collected from 78 revision total hip arthroplasties. Synovial fluid, deep tissue and swabs were obtained at the time of surgery and shipped to the laboratory for NGS analysis. Deep tissue specimens were also sent to the institutional lab for culture. PJI was diagnosed using the Musculoskeletal infection society (MSIS) definition of PJI. Thirty-four revisions were considered infected; culture was positive in 25 of these (25/34, 73.5%), while NGS was positive in 26 (26/34, 76.4%). Among the positive cultures, complete concordance between NGS and culture in 21 cases (21/25, 84.0%). 4 cases were discordant. Among these cases, 3 cases were culture-positive and NGS-negative, while 1 was both positive on NGS and culture for disparate organisms. Among the 9 cases of culture-negative PJI(CN-PJI), NGS was able to identify an organism in 4 cases (4/9, 44.4%). The remaining 5 cases were negative on both NGS and culture (5/9, 55.6%). Forty-four revisions were considered to be aseptic; NGS exclusively identified microbes in 7 of 44 “aseptic” revisions (15.9%) and culture exclusively isolated an organism in 3 of 44 cases (6.8%). Both NGS and culture were positive in 1 of case however the result was discordant. The remaining cases (33/44, 75.0%) were both NGS and culture negative. NGS detected several organisms in most positive samples, with a greater number of organisms detected in aseptic compared to septic cases (7 vs. 3.7, respectively). NGS may be a promising technique for identifying the infecting organism in PJI. Our findings suggest that some cases of PJI may be polymicrobial that escape detection using conventional culture.
