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Background: The concordance between preoperative synovial fluid culture and multiple intraoperative tissue cultures for identifying pathogenic microorganisms in periprosthetic joint infection (PJI) remains unknown. Our aim is to determine the diagnostic performance of synovial fluid culture for early organism identification., Methods: A total of 363 patients who met Musculoskeletal Infection Society criteria for PJI following primary total joint arthroplasty were identified from a retrospective joint infection database. Inclusion criteria required a positive preoperative intra-articular synovial fluid sample within 90 days of intraoperative tissue culture(s) at revision surgery. Concordance was defined as matching organism(s) in aspirate and intraoperative specimens., Results: Concordance was identified in 279 (76.8%) patients with similar rates among total hip arthroplasties (77.2%) and total knee arthroplasties (76.4%, P = .86). Culture discordance occurred in 84 (23.1%) patients; 37 (10.2%) had no intraoperative culture growth and 33 (90.1%) were polymicrobial. Monomicrobial Staphylococcal PJI cases had high sensitivity (0.96, 95% confidence interval [CI] 0.92-0.98) and specificity (0.85, 95% CI 0.80-0.90). Polymicrobial infections had the lowest sensitivity (0.06, 95% CI 0.01-0.19)., Conclusion: Aspiration culture has favorable sensitivity and specificity when compared to tissue culture for identifying the majority of PJI organisms. Clinicians can guide surgical treatment and postoperative antibiotics based on monomicrobial aspiration results, but they should strongly consider collecting multiple tissue cultures to maximize the chance of identifying an underlying polymicrobial PJI., Level of Evidence: Level III., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Debridement, antibiotics, and implant retention (DAIR) failure remains high for total hip and knee arthroplasty periprosthetic joint infection (PJI). We sought to determine the predictive value of the CRIME80 and KLIC for failure of DAIR in acute hematogenous (AH) and acute postoperative (AP) PJIs, respectively., Methods: We identified 134 patients who underwent DAIR for AH PJI with <4 weeks of symptoms after index arthroplasty and 122 patients who underwent DAIR for AP PJI <90 days from index. In the AH group, 15 patients (11%) failed at 90 days and overall, 33 (25%) had failed by 2 years. In the AP group, 39 (32%) failed at 90 days and overall, 52 (43%) failed by 2 years. Logistic regression models were used to determine the area under the curve (AUC) to establish thresholds using the Youden index., Results: For the AP cohort, AUCs were below 0.66 for KLIC, Charlson comorbidity index, Elixhauser comorbidity index, and McPherson host grade. For the AH cohort, 90-day AUCs were 0.70 for CRIME80 and below 0.66 for Charlson comorbidity index, Elixhauser comorbidity index, and McPherson host grade. In multivariate analysis controlling for age, sex, and body mass index, the CRIME80 AUC improved to 0.77 at 90 days., Conclusion: To the authors' knowledge, this study represents the first external validation of the KLIC and CRIME80 for predicting DAIR failure in a North American population. The results indicate that alternative methods for predicting DAIR failure at 90 days and 2 years for acute PJI are needed., Level of Evidence: Prognostic III., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Reported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends., Methods: A retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty., Results: The proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04)., Conclusion: The proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Periprosthetic joint infection (PJI) after unicompartmental knee arthroplasty (UKA) is a devastating but poorly understood complication, with a paucity of published data regarding treatment and outcomes. This study analyzes the largest cohort of UKA PJIs to date comparing treatment outcome, septic and aseptic reoperation rates, and risk factors for treatment failure., Methods: Twenty-one UKAs in 21 patients treated for PJI, as defined by Musculoskeletal Infection Society criteria, were retrospectively reviewed. Minimum and mean follow-up was 1 and 3.5 years, respectively. Fourteen (67%) patients had acute postoperative PJIs. Surgical treatment included 16 debridement, antibiotics, and implant retentions (DAIRs) (76%), 4 two-stage revisions (19%), and 1 one-stage revision (5%). Twenty (95%) PJIs were culture positive with Staphylococcus species identified in 15 cases (71%)., Results: Survivorship free from reoperation for infection at 1 year was 76% (95% confidence interval, 58%-93%). Overall survival from all-cause reoperation was 57% (95% confidence interval, 27%-87%) at 5 years. Two additional patients (10%) underwent aseptic revision total knee arthroplasty for lateral compartment degeneration 1 year after DAIR and tibial aseptic loosening 2.5 years after 2-stage revision. All patients who initially failed PJI UKA treatment presented with acute postoperative PJIs (5 of 14; 36%)., Conclusion: Survivorship free from persistent PJI at 1 year is low at 76% but is consistent with similar reports of DAIRs for total knee arthroplasties. Furthermore, there is low survivorship free from all-cause reoperation of 71% and 57% at 2 and 5 years, respectively. Surgeons should be aware of these poorer outcomes and consider treating UKA PJI early and aggressively., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The risk of prosthetic joint infection increases with Staphylococcus aureus colonization. The cost-effectiveness of decolonization is controversial. We evaluated cost-effectiveness decolonization protocols in high-risk arthroplasty patients., Methods: An analytical model evaluated risk under 3 protocols: 4 swabs, 2 swabs, and nasal swab alone. These were compared to no-screening and universal decolonization strategies. Cost-effectiveness was evaluated from the hospital, patient, and societal perspective., Results: Under base case conditions, universal decolonization and 4-swab strategies were most effective. The 2-swab and universal decolonization strategy were most cost-effective from patient and societal perspectives. From the hospital perspective, universal decolonization was the dominant strategy (much less costly and more effective)., Conclusion: S aureus decolonization may be cost-effective for reducing prosthetic joint infections in high-risk patients. These results may have important implications for treatment of patients and for cost containment in a bundled payment system., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Previous work has suggested a failed irrigation and debridement (I&D) before a 2-stage exchange negatively impacts the outcome of the subsequent 2-stage revision., Methods: This was a retrospective review of 132 patients who underwent a 2-stage exchange without prior I&D (2-Stage), and 45 patients had a failed I&D before their 2-stage exchange (I&D+2Stage) between April 2009 and April 2015. Charts were reviewed for patient demographics, presenting inflammatory laboratory values, type of antibiotic spacer used, surgical details, microbiology data, length of postoperative antibiotic treatment, and reoperation. A logistic regression was used to assess the association between I&D and reoperation., Results: The I&D+2Stage group had an 82.2% success rate, and the 2-Stage group had an 82.5% success rate (P = .95). The odds of reoperation for infection with the use of greater than 2 grams of vancomycin was 0.33 (P = .01, 95% confidence interval 0.14-0.79) as compared with having less than 2 grams of vancomycin in the construct. Spacer type, having a prior I&D to the 2-stage procedure, being infected with an antibiotic resistant organism, total grams of aminoglycoside were not associated with a risk of failure., Conclusion: Success rates between the I&D+2Stage group and the 2-Stage group were similar. The use of greater than 2 grams of vancomycin in the spacer construct decreased the odds of reoperation. I&D before a 2-stage exchange may not negatively influence the outcomes of a subsequent 2-stage revision procedure and requires further investigation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Propionibacterium acnes is a common cause of upper extremity arthroplasty infection and usually presents in an indolent subacute fashion. It is not well described how total knee arthroplasty (TKA) patients infected with P acnes present., Methods: We retrospectively compared patients undergoing revision TKA for infection from P acnes and methicillin-sensitive Staphylococcal aureus (MSSA) in our institutional infection database. Patients were classified as having a periprosthetic joint infection based on the Musculoskeletal Infection Society criteria and were excluded if they had a polymicrobial culture. Patient demographics, preoperative laboratory values, microbiology data, and synovial fluid white blood cell (WBC) counts were analyzed., Results: Sixteen patients with a P acnes and 30 with an MSSA TKA periprosthetic joint infection were identified. Median erythrocyte sedimentation rate was significantly higher in the MSSA group compared to the P acnes group (56.0 mm/h; interquartile range [IQR], 44.3-72.9 vs 23.0 mm/h; IQR, 18.5-52.0; respectively, P = .03) as were C-reactive protein levels (5.9 mg/dL; IQR, 3.7-26.9 vs 2.0 mg/dL; IQR, 0.5-14.0; respectively, P = .04). WBC count, synovial fluid WBC, and percentage of synovial polymorphonuclear cells were similar between groups. Mean time to culture was 8.3 ± 2.0 days in the P acnes group and 1.8 ± 0.8 days in the MSSA group., Conclusion: P acnes TKA infections are associated with more acute inflammatory symptoms than typically appreciated, and long hold anaerobic cultures up to 14 days are necessary to accurately identify this organism as the causative agent of TKA periprosthetic infection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Literature addressing the risks of barbed suture in arthroplasty remains limited. No study to our knowledge has compared rates of wound infection between barbed and conventional suture after unicompartmental knee arthroplasty (UKA). We hypothesized that barbed suture would be associated with an increased risk of wound infection in patients undergoing UKA., Methods: Electronic records were retrieved for 1040 UKA procedures. Odds ratios with postoperative wound infection as the outcome and barbed suture as the exposure were calculated. Binary logistic regression corrected for age, gender, body mass index, operative time, and risk factors (smoking, diabetes, renal insufficiency, and immunosuppression). Barbed suture consisted of Quill #2 polydioxanone (or #0 Vicryl) for deep closure and Quill 2-0 Monoderm for subcuticular closure. Conventional suture consisted of #0 Vicryl for deep closure and subcuticular 2-0 Monocryl or staples for skin closure., Results: A total of 839 procedures were included. Barbed suture was used in 333 surgeries, and conventional suture was used in 506. Eight cases of postoperative wound infection were identified. All infections occurred in the barbed suture cohort. Regression analysis revealed an association between subcuticular barbed suture and postoperative wound infection (odds ratio = 22.818, confidence interval = 2.69-2923.91; P = .0074)., Conclusions: The findings indicate that the use of barbed suture in subcuticular layer closure is associated with an increased risk of wound infection. This may be exacerbated by early intensive mobilization, commonly undertaken after UKA to permit rapid functional return. We recommend against the use of barbed suture for subcuticular layer closure in UKA., (Copyright © 2016 Elsevier Inc. All rights reserved.)