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Purpose: Total hip and knee arthroplasty in patients with previous history of periarticular surgery, such as osteosynthesis, can be surprisingly complex. This type of procedure is known as conversion arthroplasty (cTHA or cTKA) and has a higher risk of complications. The rates of unexpected positive cultures (UPC) and the risk of periprosthetic joint infection (PJI) compared to primary arthroplasty is unclear. The main purpose of this study was to evaluate rates of Unexpected Positive Cultures (UPC) in a series of conversion arthroplasty patients. The main questions to answer are: 1. Are the patients with conversion arthroplasties more susceptible to UPC than other causes of revision arthroplasties? 2. Are the conversion patients with UPC more susceptible to developing PJI?, Methods: This was a retrospective review of patients submitted to cTHA and cTKA from January 2012 to September 2018. Patients with history of previous infection or with missing intraoperative cultures were excluded. The UPC was defined as a single positive culture obtained during a procedure previously considered aseptic and PJI was defined according to the 2018 ICM criteria. After excluding 141 cases, 205 patients were analyzed, 160 hips and 45 knees., Results: Nine (4.4%) UPC were identified, five (3.1%) in the hip group and four (8,9%) in the knee group. Staphylococcal species were the most common isolated bacteria (n = 7, 77.7%). During the study period, four (1,9%) patients were diagnosed with PJI. Only one case had an UPC and a different germ was identified during revision arthroplasty workup., Conclusions: While UPC are more prevalent in conversion knee arthroplasties compared to conversion hip arthroplasties, the rates are similar to those observed in revision arthroplasty for other indications. Importantly, the presence of a UPC in conversion arthroplasty does not appear to elevate the risk of subsequent periprosthetic joint infection, provided a thorough PJI workup has been conducted preoperatively. Therefore, in such cases, UPCs may be safely disregarded., Competing Interests: Declarations Consent for publication Not applicable. Informed consent Not applicable. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: The purpose of this study was to evaluate the management and results of our standarized protocol for preoperative identification of MRSA colonisation in patients undergoing primary total hip and knee replacement procedures., Methods: Following hospital protocol, between January 2016 and June 2019 37,745 patients awaiting elective joint replacement underwent a standardized questionnaire to assess the risk of MRSA infection, identifying patients requiring preoperative MRSA screening. An evaluation of the questionnaire identified effective questions for identifying infected patients. Furthermore, an analysis evaluated the impact of comorbidities or Charlson Comorbidity Index scores on positive MRSA colonization. Additionally, we evaluated the cost savings of targeted testing compared to testing all surgery patients., Results: Of the 37,745 patients, 8.057 (21.3%) were swabbed, with a total of 65 (0.81%) positive tests. From this group 27 (36.48%) who were treated were negative before surgery. Some of the questionnaire results were consistently associated with a higher chance of colonization, including hospitalization during the past year (47,7%), previous history of MRSA (44,6%), and agriculture or cattle farming related work (15,4%). By selectively testing high-risk patients identified through the questionnaire, we achieved a 79% reduction in costs compared to universal MRSA screening., Conclusion: Our results suggest that the simple and standardized questionnaire is a valuable tool for preoperative screening, effectively identifying high-risk patients prone to MRSA colonisation. The risk of periprosthetic joint infection (PJI) and its associated sequelae may be reduced by this approach., Competing Interests: Declarations. Ethical approval: Ethical approval was waived by the local Ethics Committee in view of the retrospective nature of the study and all the procedures being performed were part of the routine care. Consent to participate: All participants gave their consent. Consent to publish: All participants gave their consent. Competing interests: T.G. is paid consultant for Waldemar Link and Zimmer Biomet. M.C. is a paid consultant for Waldemar Link., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Rheumatoid arthritis (RA) is a risk factor for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of this study was to perform a systematic review comparing the failure rates of debridement, antibiotics, and implant retention (DAIR), one-stage exchange arthroplasty/revision (OSR), and 2-stage exchange arthroplasty/revision (TSR) for RA patients with PJI and identify risk factors in the RA population associated with increased treatment failure rate., Methods: PubMed, Ovid MEDLINE, and Ovid Embase databases were screened with the terms "rheumatoid arthritis," "total joint arthroplasty," "prosthetic joint infection," and "treatment for PJI" on August 29, 2021. Four hundred ninety-one studies were screened, of which 86 were evaluated. The primary outcome evaluated was failure of surgical treatment for PJI., Results: Ten retrospective cohort studies were included after full-text screening, yielding 401 patients with RA. Additional demographic and PJI management data were obtained for 149 patients. Patients with RA who underwent TSR demonstrated a lower failure rate (26.8%) than both DAIR (60.1%) and OSR (39.2%) (χ2 = 37.463, p < 0.00001). Patients with RA who underwent DAIR had a 2.27 (95% CI, 1.66-3.10) times higher risk of experiencing treatment failure than those who underwent TSR. Among risk factors, there was a significant difference in the C-reactive protein of patients who did vs. did not experience treatment failure (p = 0.02)., Conclusion: TSR has a higher rate of success in the management of PJI patients with RA compared with DAIR and OSR. The complete removal of the infected prosthesis and delayed reimplantation may lower the treatment failure rate., Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B59)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Hepatitis B and C are important and relatively common health issues. It is known that many patients who underwent total knee and hip arthroplasty were also diagnosed with hepatitis. These patients are at higher risk of periprosthetic joint infection (PJI). This study aimed to investigate the differences in PJI cases in hepatitis B and C patients., Methods: This is a retrospective case-controlled single-center study. A total of 270 patients with hepatitis and non-hepatitis (control group) who underwent one-stage septic exchange to the hip and knee joints were included in the study. All patients' previous surgical histories, infective organisms, C-reactive protein (CRP) values before septic exchange, and demographic data were evaluated. All microbiological and laboratory evaluations were performed separately for knee and hip arthroplasty., Results: The mean CRP levels of Hep B- and C-positive patients, who underwent one-stage septic exchange in the knee joint, were 23.6 mg/L. In the control group, this value was 43.1 mg/L and a statistically significant difference was found between the groups (p = 0.004). Gram-negative organisms were identified in a larger proportion of patients with hepatitis who developed PJI in both hip and knee joints and underwent one-stage septic exchange (p = 0.041/p = 0.044)., Conclusion: PJIs caused by Gram-negative bacteria are encountered more frequently in patients with hepatitis than in the control group. In addition, the CRP rise is less in patients with hepatitis compared to PJI cases in the control group. Patient-specific evaluation is required in cases of PJI in patient groups with co-existing hepatitis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: The study aimed to analyze the efficacy of the blood management protocol developed by our team for patients who are Jehovah's Witnesses (JW) presenting for primary total hip replacement (THR)., Patients and Methods: Thirty JW patients (6 males, 24 females; mean age: 70.1±9.8 years; range, 65 to 81 years) and 30 age- and sex-matched controls (6 males, 24 females; mean age: 68.7±9.1 years; range, 62 to 79 years) who underwent primary THR at our institution between January 2018 and June 2020 were retrospectively evaluated. While the surgical technique of THR was not different among the groups, blood loss management differed between the groups. Patients in the control group were given 1 g of intravenous tranexamic acid (TXA) 15 min before the surgical incision. In addition to the same TXA protocol, intraoperative cell salvage with a continuous autologous transfusion system was used for JW patients. The estimated blood loss (EBL) was determined using Meunier's formula. Hemoglobin (Hgb) decline, EBL on the first and third postoperative days, allogenic blood transfusion (ABT) requirement, and complications were analyzed between groups., Results: There were no significant differences between groups regarding demographic and clinical characteristics (p>0.05), ABT requirement (p>0.999), and Hgb decline in the first and third postoperative days (p=0.540 and p=0.836, respectively). Furthermore, both groups did not significantly differ between EBL in the first and third postoperative days (p=0.396 and p=0.616, respectively) and the length of hospital stay (p=0.547). Similar complication rates were noted for both groups. Hemoglobin level assessments revealed that values on the first and third postoperative days were significantly lower than the baseline Hgb value in both cohorts (p<0.001)., Conclusion: A combination of intravenous administration of 1 g of TXA, meticulous hemostasis, and intraoperative use of cell saver constitutes a reasonable strategy for achieving the goal of transfusion-free primary THR with predictable levels of blood loss that are similar to non-JW patients.

Case: We present a male patient of low socioeconomic status and Māori ethnicity who experienced 3 episodes of presumed culture-negative septic arthritis of the native hip between ages 43 and 52 years. Each episode occurred within 3 weeks of intramuscular antipsychotic injection into the ipsilateral gluteal muscles. The right hip was involved in 2 presentations and the left hip in 1 presentation. No coexisting infection or underlying immune suppression was identified, and at follow-up 2 years after the last episode, he has no sequelae of septic arthritis., Conclusion: This report describes 3 episodes of presumed culture-negative septic arthritis after intramuscular antipsychotic injection., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C203)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Despite numerous studies focusing on periprosthetic joint infections (PJIs), there are no robust data on the risk factors and timing of metachronous infections. Metachronous PJIs are PJIs that can arise in the same or other artificial joints after a period of time, in patients who have previously had PJI. Between January 2010 and December 2018, 661 patients with multiple joint prostheses in situ were treated for PJI at our institution. Of these, 73 patients (11%) developed a metachronous PJI (periprosthetic infection in patients who have previously had PJI in another joint, after a lag period) after a mean time interval of 49.5 months (SD 30.24; 7 to 82.9). To identify patient-related risk factors for a metachronous PJI, the following parameters were analyzed: sex; age; BMI; and pre-existing comorbidity. Metachronous infections were divided into three groups: Group 1, metachronous infections in ipsilateral joints; Group 2, metachronous infections of the contralateral lower limb; and Group 3, metachronous infections of the lower and upper limb. We identified a total of 73 metachronous PJIs: 32 PJIs in Group 1, 38 in Group 2, and one in Group 3. The rate of metachronous infection was 11% (73 out 661 cases) at a mean of four years following first infection. Diabetes mellitus incidence was found significantly more frequently in the metachronous infection group than in non-metachronous infection group. The rate of infection in Group 1 (21.1%) was significantly higher (p = 0.049) compared to Groups 2 (6.2%) and 3 (3%). The time interval of metachronous infection development was shorter in adjacent joint infections. Concordance between the bacterium of the first PJI and that of the metachronous PJI in Group 1 (21/34) was significantly higher than Group 2 (13/38; p = 0.001). The findings of this study suggest that metachronous PJI occurs in more than one in ten patients with an index PJI. Female patients, diabetic patients, and patients with a polymicrobial index PJI are at significantly higher risk for developing a metachronous PJI. Furthermore, metachronous PJIs are significantly more likely to occur in an adjacent joint (e.g. ipsilateral hip and knee) as opposed to a more remote site (i.e. contralateral or upper vs lower limb). Additionally, adjacent joint PJIs occur significantly earlier and are more likely to be caused by the same bacteria as the index PJI., Competing Interests: M. Citak reports speaker payments from Waldemar-Link, unrelated to this study. S. Ekhtiari reports fellowship support from the ME Müller Foundation/Hip Society European Fellowship, and research grants from the PSI Foundation, the Michael G. DeGroote Foundation, and the Research Institute of St Joe's Hamilton, all of which are unrelated to this study. T. Gehrke reports speaker payments from Zimmer-Biomet, Waldemar-Link, 3M, and Ceramic, unrelated to this study., (© 2023 The British Editorial Society of Bone & Joint Surgery.)

Purpose: Acromegaly is a rare and chronic hormonal disorder. Persons with acromegaly frequently live well into adulthood. Patients with active acromegaly have multiple joint-related issues; however, acromegalic arthropathy (AA), which is secondary osteoarthritis (OA), is considered one of the most common musculoskeletal complications of acromegaly. This study aims to analyze a cohort of patients who underwent total hip arthroplasty (THA) for AA at our institution and present the long-term clinical outcomes and causes of revision in these patients., Methods: All patients, who underwent total hip arthroplasty due to secondary osteoarthritis related to acromegaly between January 2001 and December 2019 at our institution, were included in this retrospective study. There were 15 patients (22 hips) with a mean follow-up of 12 years (range 4-20). Survivorship free of component revision was determined using Kaplan-Meier analysis. Patient-reported clinical outcomes were assessed using Harris Hip Scores., Results: At the final follow-up, the status of the implant was known in all 15 hips. No patients were lost to follow-up. Five patients (9 hips) were deceased. Three hips (14%) underwent a revision surgery at a mean of six years (range 3-10). Survivorship free of component revision was 81% at 15 years. Mean Harris Hip Scores at final follow-up were fair (mean 64.3, range 32-91), but significantly improved compared to preoperative scores (p < 0.05)., Conclusion: Acromegaly is a rare disorder that has direct effects on bone and joints. Our results suggest that THA can result in successful clinical and functional outcomes in patients with AA of the hip however the risk of aseptic loosening should also be considered in this patient population., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Background: This study was performed to answer the question: Is the risk of PJI in patients undergoing primary TKA and THA in multi-unit OR higher than in a classical single-unit OR? We hypothesized that the risk of PJI following TKA and THA is not associated with the OR type., Methods: We reviewed the medical records of all cases of THA and TKA in our centre, between January 2015 and September 2018, in our single- and multi-unit OR. A total of 8674 patients met the inclusion criteria. Patients were divided into two groups: group 1, surgery in the multi-unit OR (n = 8282); group 2, surgery in the single-unit OR (n = 450). The infection rate between both groups was compared using chi-square test., Results: There was no significant difference between both groups regarding the septic revision rate at three (p = 0.1 and 0.58 respectively) and six months post-operatively (p = 0.22 and 0.7 respectively). In group 1, five patients after TKA and 4 patients after THA were revised within three months. At six months, 11 patients after TKA and six patients after THA required revision surgery. In group 2, one patient after TKA and one patient after THA were revised within three months. At six months, one patient after TKA and one patient after THA underwent revision surgery., Conclusion: The incidence of SSI does not differ significantly based on OR design in patients undergoing TKA and THA. The number of patients per surgical table in multi-unit OR is higher than in the single-unit OR. This shows that more number of surgeries can be achieved in multi-unit OR and as safe as single-unit OR., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)