Aims. Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international
Aims. To review the evidence and reach
Aims. The extended wait that most patients are now experiencing for hip and knee arthroplasty has raised questions about whether reliance on waiting time as the primary driver for prioritization is ethical, and if other additional factors should be included in determining surgical priority. Our Prioritization of THose aWaiting hip and knee ArthroplastY (PATHWAY) project will explore which perioperative factors are important to consider when prioritizing those on the waiting list for hip and knee arthroplasty, and how these factors should be weighted. The final product will include a weighted benefit score that can be used to aid in surgical prioritization for those awaiting elective primary hip and knee arthroplasty. Methods. There will be two linked work packages focusing on opinion from key stakeholders (patients and surgeons). First, an online modified Delphi process to determine a
Aims. The aim of this study was to determine the diagnostic accuracy of α defensin (AD) lateral flow assay (LFA) and enzyme-linked immunosorbent assay (ELISA) tests for periprosthetic joint infection (PJI) in comparison to conventional synovial white blood cell (WBC) count and polymorphonuclear neutrophil percentage (PMN%) analysis. Methods. Patients undergoing joint aspiration for evaluation of pain after total knee arthroplasty (TKA) or total hip arthroplasty (THA) were considered for inclusion. Synovial fluids from 99 patients (25 THA and 74 TKA) were analyzed by WBC count and PMN% analysis, AD LFA, and AD ELISA. WBC and PMN% cutoffs of ≥ 1,700 cells/mm. 3. and ≥ 65% for TKA and ≥ 3,000 cells/mm. 3. and ≥ 80% for THA were used, respectively. A panel of three physicians, all with expertise in orthopaedic infections and who were blinded to the results of AD tests, independently reviewed patient data to diagnose subjects as with or without PJI.
Aims. The aim of this study was to evaluate the optimal deep tissue specimen sample number for histopathological analysis in the diagnosis of periprosthetic joint infection (PJI). Methods. In this retrospective diagnostic study, patients undergoing revision surgery after total hip or knee arthroplasty (n = 119) between January 2015 and July 2018 were included. Multiple specimens of the periprosthetic membrane and pseudocapsule were obtained for histopathological analysis at revision arthroplasty. Based on the Infectious Diseases Society of America (IDSA) 2013 criteria, the International
Aims. The aim of this study was to evaluate the diagnostic accuracy of the absolute synovial polymorphonuclear neutrophil cell (PMN) count for the diagnosis or exclusion of periprosthetic joint infection (PJI) after total hip (THA) or knee arthroplasty (TKA). Methods. In this retrospective cohort study, 147 consecutive patients with acute or chronic complaints following THA and TKA were included. Diagnosis of PJI was established based on the 2018 International
Aims. This study aimed to develop a virtual clinic for the purpose of reducing face-to-face orthopaedic consultations. Patients and Methods. Anonymized experts (hip and knee arthroplasty patients, surgeons, physiotherapists, radiologists, and arthroplasty practitioners) gave feedback via a Delphi
Aims. Periprosthetic hip and knee infection remains one of the most severe complications following arthroplasty, with an incidence between 0.5% to 1%. This study compares the outcomes of revision surgery for periprosthetic joint infection (PJI) following hip and knee arthroplasty prior to and after implementation of a specialist PJI multidisciplinary team (MDT). Methods. Data was retrospectively analyzed from a single centre. In all, 29 consecutive joints prior to the implementation of an infection MDT in November 2016 were compared with 29 consecutive joints subsequent to the MDT conception. All individuals who underwent a debridement antibiotics and implant retention (DAIR) procedure, a one-stage revision, or a two-stage revision for an acute or chronic PJI in this time period were included. The definition of successfully treated PJI was based on the Delphi international multidisciplinary
Aims. The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no
Aims. Preoperative nasal Staphylococcus aureus screening and eradication reduces surgical site infections (SSIs) but its impact on reducing early prosthetic joint infection (PJI) remains controversial. This study aims to assess the effect of preoperative nasal S. aureus screening and eradication on the incidence of early PJI in general and S. aureus-induced early PJI. Methods. All primary total hip arthroplasties (THA) and total knee arthroplasties (TKA) performed from January 2006 to April 2018 were retrospectively reviewed for the incidence of early PJI. Demographic parameters, risk factors for PJI (American Society of Anaesthesiologists classification, body mass index, smoking status, and diabetes mellitus) and implant types were collected. A preoperative screening and eradication protocol for nasal colonization of S. aureus was introduced in October 2010. The incidence of early PJI was compared before and after the implementation of the protocol. Missing data were imputed via multiple imputation by chained equations. Inverse probability weighting was used to account for differences between patients in both groups. Weighted univariate logistic regression was used to evaluate the incidence of early PJI for both groups. Results. In total, 10,486 THAs and TKAs were performed in the research period. After exclusion, a cohort of 5,499 screened cases and 3,563 non-screened cases were available for analysis. Overall, no significant reduction in early PJI was found in the screened group (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.55 to 1.11; p = 0.173). However, the incidence of S. aureus-induced PJI was significantly reduced (OR 0.58, 95% CI 0.36 to 0.92; p = 0.027) in the screened group. Conclusion. A preoperative nasal S. aureus screening and eradication protocol did not significantly reduce the overall incidence of early PJI after THA or TKA. However, a decreased incidence of S. aureus-induced early PJI was established. These findings can help to establish better
Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated.Aims
Methods
Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery.Aims
Methods
The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA). This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC.Aims
Methods
The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery. This is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undertaken of arthroplasty patients at both sites.Aims
Methods
The surgical helmet system (SHS) was developed to reduce the risk of periprosthetic joint infection (PJI), but the evidence is contradictory, with some studies suggesting an increased risk of PJI due to potential leakage through the glove-gown interface (GGI) caused by its positive pressure. We assumed that SHS and glove exchange had an impact on the leakage via GGI. There were 404 arthroplasty simulations with fluorescent gel, in which SHS was used (H+) or not (H-), and GGI was sealed (S+) or not (S-), divided into four groups: H+S+, H+S-, H-S+, and H-S-, varying by exposure duration (15 to 60 minutes) and frequency of glove exchanges (0 to 6 times). The intensity of fluorescent leakage through GGI was quantified automatically with an image analysis software. The effect of the above factors on fluorescent leakage via GGI were compared and analyzed.Aims
Methods
The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR. Two authors conducted searches in PubMed, Embase, Web of Science, and Scopus on TJR and urinary retention. Eligible studies that reported the rate of POUR and associated risk factors for patients undergoing TJR were included in the analysis. Patient demographic details, medical comorbidities, and postoperative outcomes and complications were separately analyzed. The effect estimates for continuous and categorical data were reported as standardized mean differences (SMDs) and odds ratios (ORs) with 95% CIs, respectively.Aims
Methods
While internet search engines have been the primary information source for patients’ questions, artificial intelligence large language models like ChatGPT are trending towards becoming the new primary source. The purpose of this study was to determine if ChatGPT can answer patient questions about total hip (THA) and knee arthroplasty (TKA) with consistent accuracy, comprehensiveness, and easy readability. We posed the 20 most Google-searched questions about THA and TKA, plus ten additional postoperative questions, to ChatGPT. Each question was asked twice to evaluate for consistency in quality. Following each response, we responded with, “Please explain so it is easier to understand,” to evaluate ChatGPT’s ability to reduce response reading grade level, measured as Flesch-Kincaid Grade Level (FKGL). Five resident physicians rated the 120 responses on 1 to 5 accuracy and comprehensiveness scales. Additionally, they answered a “yes” or “no” question regarding acceptability. Mean scores were calculated for each question, and responses were deemed acceptable if ≥ four raters answered “yes.”Aims
Methods
The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD. A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial.Aims
Methods
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common orthopaedic procedures requiring postoperative radiographs to confirm implant positioning and identify complications. Artificial intelligence (AI)-based image analysis has the potential to automate this postoperative surveillance. The aim of this study was to prepare a scoping review to investigate how AI is being used in the analysis of radiographs following THA and TKA, and how accurate these tools are. The Embase, MEDLINE, and PubMed libraries were systematically searched to identify relevant articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews and Arksey and O’Malley framework were followed. Study quality was assessed using a modified Methodological Index for Non-Randomized Studies tool. AI performance was reported using either the area under the curve (AUC) or accuracy.Aims
Methods
Aims. The aim of this study was to identify the incidence of positive
cultures during the second stage of a two-stage revision arthroplasty
and to analyse the association between positive cultures and an
infection-free outcome. Patients and Methods. This single-centre retrospective review of prospectively collected
data included patients with a periprosthetic joint infection (PJI)
of either the hip or the knee between 2013 and 2015, who were treated
using a standardised diagnostic and therapeutic algorithm with two-stage
exchange. Failure of treatment was assessed according to a definition
determined by a Delphi-based
Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years. This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed.Aims
Methods
Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined.Aims
Methods
In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimize exposure on wards. In order to maintain throughput of elective cases, our hospital (St Michaels Hospital, Toronto, Canada) was forced to convert as many cases as possible to same-day procedures rather than overnight admission. In this retrospective analysis, we review the cases performed as same-day arthroplasty surgeries compared to the same period in the previous 12 months. We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties over a three-month period between October and December in 2019, and again in 2020, in the middle of the COVID-19 pandemic. Patient demographics, number of outpatient primary arthroplasty cases, length of stay for admissions, 30-day readmission, and complications were collated.Aims
Methods
The success rates of two-stage revision arthroplasty for infection have evolved since their early description. The implementation of internationally accepted outcome criteria led to the readjustment of such rates. However, patients who do not undergo reimplantation are usually set aside from these calculations. The aim of this study was to investigate the outcomes of two-stage revision arthroplasty when considering those who do not undergo reimplantation, and to investigate the characteristics of this subgroup. A retrospective cohort study was conducted. Patients with chronic hip or knee periprosthetic joint infection (PJI) treated with two-stage revision between January 2010 and October 2018, with a minimum follow-up of one year, were included. Variables including demography, morbidity, microbiology, and outcome were collected. The primary endpoint was the eradication of infection. Patients who did not undergo reimplantation were analyzed in order to characterize this subgroup better.Aims
Methods
Calprotectin (CLP) is produced in neutrophils and monocytes and released into body fluids as a result of inflammation or infection. The aim of this study was to evaluate the utility of blood and synovial CLP in the diagnosis of chronic periprosthetic joint infection (PJI). Blood and synovial fluid samples were collected prospectively from 195 patients undergoing primary or revision hip and knee arthroplasty. Patients were divided into five groups: 1) primary total hip and knee arthroplasty performed due to idiopathic osteoarthritis (OA; n = 60); 2) revision hip and knee arthroplasty performed due to aseptic failure of the implant (AR-TJR; n = 40); 3) patients with a confirmed diagnosis of chronic PJI awaiting surgery (n = 45); 4) patients who have finished the first stage of the PJI treatment with the use of cemented spacer and were qualified for replantation procedure (SR-TJR; n = 25), and 5) patients with rheumatoid arthritis undergoing primary total hip and knee arthroplasty (RA; n = 25). CLP concentrations were measured quantitatively in the blood and synovial fluid using an immunoturbidimetric assay. Additionally, blood and synovial CRP, blood interleukin-6 (IL-6), and ESR were measured, and a leucocyte esterase (LE) strip test was performed.Aims
Methods
Use of molecular sequencing methods in periprosthetic joint infection (PJI) diagnosis and organism identification have gained popularity. Next-generation sequencing (NGS) is a potentially powerful tool that is now commercially available. The purpose of this study was to compare the diagnostic accuracy of NGS, polymerase chain reaction (PCR), conventional culture, the Musculoskeletal Infection Society (MSIS) criteria, and the recently proposed criteria by Parvizi et al in the diagnosis of PJI. In this retrospective study, aspirates or tissue samples were collected in 30 revision and 86 primary arthroplasties for routine diagnostic investigation for PJI and sent to the laboratory for NGS and PCR. Concordance along with statistical differences between diagnostic studies were calculated.Aims
Methods
Synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells (%PMN) are elevated at periprosthetic joint infection (PJI). Leucocytes produce different interleukins (IL), including IL-6, so we hypothesized that synovial fluid IL-6 could be a more accurate predictor of PJI than synovial fluid WBC count and %PMN. The main aim of our study was to compare the predictive performance of all three diagnostic tests in the detection of PJI. Patients undergoing total hip or knee revision surgery were included. In the perioperative assessment phase, synovial fluid WBC count, %PMN, and IL-6 concentration were measured. Patients were labeled as positive or negative according to the predefined cut-off values for IL-6 and WBC count with %PMN. Intraoperative samples for microbiological and histopathological analysis were obtained. PJI was defined as the presence of sinus tract, inflammation in histopathological samples, and growth of the same microorganism in a minimum of two or more samples out of at least four taken.Aims
Methods
Allografts of bone from the femoral head are often used in orthopaedic procedures. Although the donated heads are thoroughly tested microscopically before release by the bone bank, some surgeons take additional cultures in the operating theatre before implantation. There is no
To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores. Existing UK data from 222,933 knee and 209,760 hip arthroplasty patients were used to model an individual’s probability of gaining meaningful improvement after surgery based on their preoperative Oxford Knee or Hip Score (OKS/OHS). A clinically meaningful improvement after arthroplasty was defined as ≥ 8 point improvement in OHS, and ≥ 7 in OKS.Aims
Methods
Biopsy of the periprosthetic tissue is an important diagnostic tool for prosthetic joint infection (PJI) as it enables the detection of the responsible microorganism with its sensitivity to antibiotics. We aimed to investigate how often the bacteria identified in the tissue analysis differed between samples obtained from preoperative biopsy and intraoperative revision surgery in cases of late PJI; and whether there was a therapeutic consequence. A total of 508 patients who required revision surgery of total hip arthroplasty (THA) (n = 231) or total knee arthroplasty (TKA) (n = 277) because of component loosening underwent biopsy before revision surgery. The tissue samples collected at biopsy and during revision surgery were analyzed according to the criteria of the Musculoskeletal Infection Society (MSIS).Aims
Methods
The aims of this study were to report the efficacy of revision surgery for patients with co-infective bacterial and fungal prosthetic joint infections (PJIs) presenting to a single institution, and to identify prognostic factors that would guide management. A total of 1189 patients with a PJI were managed in our bone infection service between 2006 and 2015; 22 (1.85%) with co-infective bacterial and fungal PJI were included in the study. There were nine women and 13 men, with a mean age at the time of diagnosis of 64.5 years (47 to 83). Their mean BMI was 30.9 kg/m2 (24 to 42). We retrospectively reviewed the outcomes of these PJIs, after eight total hip arthroplasties and 14 total knee arthroplasties. The mean clinical follow-up was 4.1 years (1.4 to 8.8).Aims
Patients and Methods
The aim of this study was to evaluate the diagnostic accuracy of the synovial alpha-defensin enzyme-linked immunosorbent assay (ELISA) for the diagnosis of prosthetic joint infection (PJI) in the work-up prior to revision of total hip (THA) and knee arthroplasty (TKA). Inclusion criteria for this prospective cohort study were acute or chronic symptoms of the index joint without specific exclusion criteria. Synovial fluid aspirates of 202 patients were analyzed and semiquantitative laboratory alpha-defensin ELISA was performed. Final diagnosis of PJI was established by examination of samples obtained during revision surgery.Aims
Patients and Methods
The aim of this study was to compare the results of 16S/28S rRNA sequencing with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and synovial fluid analysis in the diagnosis of prosthetic joint infection (PJI). Between September 2015 and August 2016, 214 consecutive patients were enrolled. In the study population, there were 25 patients with a PJI and 189 controls. Of the PJI patients, 14 (56%) were women, and the mean age at the time of diagnosis was 65 years (38 to 83). The ESR and CRP levels were measured, and synovial fluid specimens were collected prospectively. Synovial fluid was subjected to reverse transcription polymerase chain reaction (RT-PCR)/sequence analysis targeting the 16S/28S rRNA, and to conventional culture. Laboratory personnel who were blind to the clinical information performed all tests. The diagnosis of PJI was based on the criteria of the Musculoskeletal Infection Society.Aims
Patients and Methods
To evaluate the effectiveness of an institutionally developed
algorithm for evaluation and diagnosis of prosthetic joint injection
and to determine the impact of this protocol on overall hospital
re-admissions.p We retrospectively evaluated 2685 total hip arthroplasty (THA)
and total knee arthroplasty (TKA) patients prior to (1263) and following
(1422) the introduction of an infection detection protocol. The
protocol used conservative thresholds for C-reactive protein to
direct the medical attendant to aspirate the joint. The protocol
incorporated a clear set of laboratory and clinical criteria that
allowed a patient to be discharged home if all were met. Patients were
included if they presented to our emergency department within 120
days post-operatively with concerns for swelling, pain or infection
and were excluded if they had an unambiguous infection or if their
chief complaint was non-orthopaedic in nature.Aims
Patients and Methods
Positive cultures are not uncommon in cases of revision total
knee and hip arthroplasty (TKA and THA) for presumed aseptic causes.
The purpose of this study was to assess the incidence of positive
intra-operative cultures in presumed aseptic revision of TKA and
THA, and to determine whether the presence of intra-operative positive cultures
results in inferior survival in such cases. A retrospective cohort study was assembled with 679 patients
undergoing revision knee (340 cases) or hip arthroplasty (339 cases)
for presumed aseptic causes. For all patients three or more separate
intra-operative cultures were obtained. Patients were diagnosed
with a previously unsuspected prosthetic joint infection (PJI) if two
or more cultures were positive with the same organism. Records were
reviewed for demographic details, pre-operative laboratory results
and culture results. The primary outcome measure was infection-free
implant survival at two years.Aims
Patients and Methods
The diagnosis of periprosthetic joint infection (PJI) remains
demanding due to limitations of all the available diagnostic tests.
The synovial fluid marker, α-defensin, is a promising adjunct for
the assessment of potential PJI. The purpose of this study was to
investigate the qualitative assessment of α-defensin, using Synovasure
to detect or exclude periprosthetic infection in total joint arthroplasty. We studied 50 patients (28 women, 22 men, mean age 65 years;
20 to 89) with a clinical indication for revision arthroplasty who
met the inclusion criteria of this prospective diagnostic study.
The presence of α-defensin was determined using the qualitative
Synovasure test and compared with standard diagnostic methods for
PJI. Based on modified Musculoskeletal Infection Society (MSIS)
criteria, 13 cases were categorised as septic and 36 as aseptic revisions.
One test was inconclusive.Aims
Patients and Methods
The purpose of this current multicentre study is to analyse the
presence of alpha-defensin proteins in synovial fluid using the
Synovasure lateral flow device and to determine its diagnostic reliability
and accuracy compared with the prosthetic joint infection (PJI)
criteria produced by the Musculoskeletal Infection Society (MSIS). A cohort of 121 patients comprising 85 total knee arthroplasties
and 36 total hip arthroplasties was prospectively evaluated between
May 2015 and June 2016 in three different orthopaedic centres. The
tests were performed on patients with a chronically painful prosthesis
undergoing a joint aspiration in a diagnostic pathway or during revision
surgery.Aims
Patients and Methods
To investigate the outcomes of treatment of streptococcal periprosthetic
joint infection (PJI) involving total knee and hip arthroplasties. Streptococcal PJI episodes which occurred between January 2009
and December 2015 were identified from clinical databases. Presentation
and clinical outcomes for 30 streptococcal PJIs in 30 patients (12
hip and 18 knee arthroplasties) following treatment were evaluated
from the medical notes and at review. The Kaplan-Meier survival method
was used to estimate the probability of infection-free survival.
The influence of the biofilm active antibiotic rifampin was also
assessed.Aims
Patients and Methods
The aims of this study were to increase the diagnostic accuracy
of the analysis of synovial fluid in the differentiation of prosthetic
joint infection (PJI) by the addition of inexpensive biomarkers
such as the levels of C-reactive protein (CRP), adenosine deaminase
(ADA), alpha-2-macrogloblulin (α2M) and procalcitonin. Between January 2013 and December 2015, synovial fluid and removed
implants were requested from 143 revision total joint arthroplasties.
A total of 55 patients met inclusion criteria of the receipt of
sufficient synovial fluid, tissue samples and removed implants for
analysis. The diagnosis of PJI followed the definition from a recent International
Consensus Meeting to create two groups of patients; septic and aseptic.
Using receiver operating characteristic curves we determined the
cutoff values and diagnostic accuracy for each marker.Aims
Patients and Methods
Vancomycin is commonly added to acrylic bone cement during revision
arthroplasty surgery. Proprietary cement preparations containing
vancomycin are available, but are significantly more expensive.
We investigated whether the elution of antibiotic from ‘home-made’
cement containing vancomycin was comparable with more expensive
commercially available vancomycin impregnated cement. A total of 18 cement discs containing either proprietary CopalG+V;
or ‘home-made’ CopalR+G with vancomycin added by hand, were made.
Each disc contained the same amount of antibiotic (0.5 g gentamycin,
2 g vancomycin) and was immersed in ammonium acetate buffer in a
sealed container. Fluid from each container was sampled at eight
time points over a two-week period. The concentrations of gentamicin
and vancomycin in the fluid were analysed using high performance
liquid chromatography mass spectrometry.Aims
Materials and Methods
Valgus knee deformity can present a number of
unique surgical challenges for the total knee arthroplasty (TKA)
surgeon. Understanding the typical patterns of bone and soft-tissue pathology
in the valgus arthritic knee is critical for appropriate surgical
planning. This review aims to provide the knee arthroplasty surgeon
with an understanding of surgical management strategies for the
treatment of valgus knee arthritis. Lateral femoral and tibial deficiencies, contracted lateral soft
tissues, attenuated medial soft tissues, and multiplanar deformities
may all be present in the valgus arthritic knee. A number of classifications
have been reported in order to guide surgical management, and a variety
of surgical strategies have been described with satisfactory clinical
results. Depending on the severity of the deformity, a variety of
TKA implant designs may be appropriate for use. Regardless of an operating surgeon’s preferred surgical strategy,
adherence to a step-wise approach to deformity correction is advised. Cite this article:
There is uncertainty regarding the optimal means of thromboprophylaxis
following total hip and knee arthroplasty (THA, TKA). This systematic
review presents the evidence for acetylsalicylic acid (aspirin)
as a thromboprophylactic agent in THA and TKA and compares it with
other chemoprophylactic agents. A search of literature published between 2004 and 2014 was performed
in accordance with Preferred Reporting Items for Systematic Reviews
and Meta-Analyses guidelines. A total of 13 studies were eligible
for inclusion.Aims
Materials and Methods
Tissue responses to debris formed by abrasion of polymethylmethacrylate
(PMMA) spacers at two-stage revision arthroplasty for prosthetic
joint infection are not well described. We hypothesised that PMMA
debris induces immunomodulation in periprosthetic tissues. Samples of tissue were taken during 35 two-stage revision arthroplasties
(nine total hip and 26 total knee arthroplasties) in patients whose
mean age was 67 years (44 to 85). Fourier transform infrared microscopy
was used to confirm the presence of PMMA particles. Histomorphometry
was performed using Sudan Red and Haematoxylin-Eosin staining.
CD-68, CD-20, CD-11(c), CD-3 and IL-17 antibodies were used to immunophenotype
the inflammatory cells. All slides were scored semi-quantitatively
using the modified Willert scoring system.Aims
Patients and Methods
We wanted to investigate regional variations in the organisms
reported to be causing peri-prosthetic infections and to report
on prophylaxis regimens currently in use across England. Analysis of data routinely collected by Public Health England’s
(PHE) national surgical site infection database on elective primary
hip and knee arthroplasty procedures between April 2010 and March
2013 to investigate regional variations in causative organisms.
A separate national survey of 145 hospital Trusts (groups of hospitals
under local management) in England routinely performing primary
hip and/or knee arthroplasty was carried out by standard email questionnaire.Objectives
Methods
To assess the responsiveness and ceiling/floor effects of the Forgotten Joint Score -12 and to compare these with that of the more widely used Oxford Hip Score (OHS) in patients six and 12 months after primary total hip arthroplasty. We prospectively collected data at six and 12 months following total hip arthroplasty from 193 patients undergoing surgery at a single centre. Ceiling effects are outlined with frequencies for patients obtaining the lowest or highest possible score. Change over time from six months to 12 months post-surgery is reported as effect size (Cohen’s d).Objectives
Methods
The purpose of this study was to evaluate the
effect of various non-operative modalities of treatment (transcutaneous
electrical nerve stimulation (TENS); neuromuscular electrical stimulation
(NMES); insoles and bracing) on the pain of osteoarthritis (OA)
of the knee. We conducted a systematic review according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses guidelines to identify
the therapeutic options which are commonly adopted for the management
of osteoarthritis (OA) of the knee. The outcome measurement tools used in the different studies were
the visual analogue scale and The Western Ontario and McMaster Universities
Arthritis Index pain index: all pain scores were converted to a
100-point scale. A total of 30 studies met our inclusion criteria: 13 on insoles,
seven on TENS, six on NMES, and four on bracing. The standardised
mean difference (SMD) in pain after treatment with TENS was 1.796,
which represented a significant reduction in pain. The significant
overall effect estimate for NMES on pain was similar to that of
TENS, with a SMD of 1.924. The overall effect estimate of insoles
on pain was a SMD of 0.992. The overall effect of bracing showed
a significant reduction in pain of 1.34. Overall, all four non-operative modalities of treatment were
found to have a significant effect on the reduction of pain in OA
of the knee. This study shows that non-operative physical modalities of treatment
are of benefit when treating OA of the knee. However, much of the
literature reviewed evaluates studies with follow-up of less than
six months: future work should aim to evaluate patients with longer
follow-up. Cite this article:
Increasing demand for total hip and knee arthroplasty (THA/TKA)
and associated follow-up has placed huge demands on orthopaedic
services. Feasible follow-up mechanisms are therefore essential. We conducted an audit of clinical follow-up decision-making for
THA/TKA based on questionnaire/radiograph review compared with local
practice of Arthroplasty Care Practitioner (ACP)-led outpatient
follow-up. In all 599 patients attending an ACP-led THA/TKA follow-up
clinic had a pelvic/knee radiograph, completed a pain/function questionnaire
and were reviewed by an ACP. An experienced orthopaedic surgeon
reviewed the same radiographs and questionnaires, without patient
contact or knowledge of the ACP’s decision. Each pathway classified
patients into: urgent review, annual monitoring, routine follow-up
or discharge. Aims
Methods
Infection is a leading indication for revision
arthroplasty. Established criteria used to diagnose prosthetic joint infection
(PJI) include a range of laboratory tests. Leucocyte esterase (LE)
is widely used on a colorimetric reagent strip for the diagnosis
of urinary tract infections. This inexpensive test may be used for
the diagnosis or exclusion of PJI. Aspirates from 30 total hip arthroplasties
(THAs) and 79 knee arthroplasties (KA) were analysed for LE activity. Semi-quantitative
reagent strip readings of 15, 70, 125 and 500 white blood cells
(WBC) were validated against a manual synovial white cell count
(WCC). A receiver operating characteristic (ROC) curve was constructed
to determine the optimal cut-off point for the semi-quantitative
results. Based on established criteria, six THAs and 15 KAs were
classified as infected. The optimal cut-off point for the diagnosis
of PJI was 97 WBC. The closest semi-quantitative reading for a positive
result was 125 WBC, achieving a sensitivity of 81% and a specificity
of 93%. The positive and negative predictive values of the LE test
strip were 74% and 95% respectively. The LE reagent strip had a high specificity and negative predictive
value. A negative result may exclude PJI and negate the need for
further diagnostic tests. Cite this article:
If patients could recall their physical status
before total hip (THA) or knee arthroplasty (TKA) accurately it
could have valuable applications both clinically and for research.
This study evaluated the accuracy of a patient’s recollection one
year after either THA or TKA using the Oxford hip or knee scores
(OHS and OKS). In total, 113 patients (59 THA, 54 TKA) who had completed
the appropriate score pre-operatively were asked to complete the
score again at a mean of 12.4 months (standard deviation ( While there were no significant differences between the actual
and recalled pre-operative scores (OHS mean difference 0.8, A patient’s recollection of pre-operative pain and function is
inaccurate one year after THA or TKA. Cite this article:
Wear debris released from bearing surfaces has been shown to
provoke negative immune responses in the recipient. Excessive wear
has been linked to early failure of prostheses. Analysis using coordinate
measuring machines (CMMs) can provide estimates of total volumetric
material loss of explanted prostheses and can help to understand
device failure. The accuracy of volumetric testing has been debated,
with some investigators stating that only protocols involving hundreds
of thousands of measurement points are sufficient. We looked to
examine this assumption and to apply the findings to the clinical
arena. We examined the effects on the calculated material loss from
a ceramic femoral head when different CMM scanning parameters were
used. Calculated wear volumes were compared with gold standard gravimetric
tests in a blinded study. Objectives
Methods
We report a systematic review and meta-analysis
of the peer-reviewed literature focusing on metal sensitivity testing
in patients undergoing total joint replacement (TJR). Our purpose
was to assess the risk of developing metal hypersensitivity post-operatively
and its relationship with outcome and to investigate the advantages
of performing hypersensitivity testing. We undertook a comprehensive search of the citations quoted in
PubMed and EMBASE: 22 articles (comprising 3634 patients) met the
inclusion criteria. The frequency of positive tests increased after
TJR, especially in patients with implant failure or a metal-on-metal
coupling. The probability of developing a metal allergy was higher
post-operatively (odds ratio (OR) 1.52 (95% confidence interval
(CI) 1.06 to 2.31)), and the risk was further increased when failed
implants were compared with stable TJRs (OR 2.76 (95% CI 1.14 to
6.70)). Hypersensitivity testing was not able to discriminate between
stable and failed TJRs, as its predictive value was not statistically
proven. However, it is generally thought that hypersensitivity testing
should be performed in patients with a history of metal allergy
and in failed TJRs, especially with metal-on-metal implants and
when the cause of the loosening is doubtful.
Patients who have undergone total hip or knee replacement (THR and TKR, respectively) are at high risk of venous thromboembolism. We aimed to determine the time courses of both the incidence of venous thromboembolism and effective prophylaxis. Patients with elective primary THR and TKR were enrolled in the multi-national Global Orthopaedic Registry. Data on the incidence of venous thromboembolism and prophylaxis were collected from 6639 THR and 8326 TKR patients. The cumulative incidence of venous thromboembolism within three months of surgery was 1.7% in the THR and 2.3% in the TKR patients. The mean times to venous thromboembolism were 21.5 days ( The risk of venous thromboembolism extends beyond the usual period of hospitalisation, while the duration of prophylaxis is often shorter than this. Practices should be re-assessed to ensure that patients receive appropriate durations of prophylaxis.
Infection remains a significant and common complication after joint replacement and there is debate about which contributing factors are important. Few studies have investigated the effect of the operating time on infection. We collected data prospectively from 5277 hip and knee replacements which included the type of procedure, the operating time, the use of drains, the operating theatre, surgeon, age and gender. In a subgroup of 3449 knee replacements further analysis was carried out using the tourniquet time in place of the operating time. These variables were assessed by the use of generalised linear modelling against superficial, deep or joint-space post-operative infection as defined by the Australian Surgical-Site Infection criteria. The overall infection rate was 0.98%. In the replacement data set both male gender (z = 3.097, p = 0.00195) and prolonged operating time (z = 4.325, p <
0.001) were predictive of infection. In the knee subgroup male gender (z = 2.250, p = 0.02447), a longer tourniquet time (z = 2.867, p = 0.00414) and total knee replacement ( These findings support the view that a prolonged operating time and male gender are associated with an increased incidence of infection. Steps to minimise intra-operative delay should be instigated, and care should be exercised when introducing measures which prolong the duration of joint replacement.
The National Institute for Clinical Excellence (NICE) produces recommendations on appropriate treatment within the National Health Service (NHS) in England and Wales. The NICE guidelines on prophylaxis for venous thromboembolism in orthopaedic surgery recommend that all patients be offered a low molecular weight heparin (LMWH). The linked hospital episode statistics of 219 602 patients were examined to determine the rates of complications following lower limb arthroplasty for the 12-month periods prior to and following the publication of these guidelines. These were compared with data from the National Joint Registry (England and Wales) regarding the use of LMWH during the same periods. There was a significant increase in the reported use of LMWH (59.5% to 67.6%, p <
0.001) following the publication of the guidelines. However, the 90-day venous thromboembolism events actually increased slightly following total hip replacement (THR, 1.69% to 1.84%, p = 0.06) and remained unchanged following total knee replacement (TKR, 1.99% to 2.04%). Return to theatre in the first 30 days for infection did not show significant changes. There was an increase in the number of patients diagnosed with thrombocytopenia, which was significant following THR (0.11% to 0.16%, p = 0.04). The recommendations from NICE are based on predicted reductions in venous thromboembolism events, reducing morbidity, mortality and costs to the NHS. The early results in orthopaedic patients do not support these predictions, but do show an increase in complications.