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We report the results of a first-in-human phase 1 clinical study to evaluate TRL1068, a native human monoclonal antibody that disrupts bacterial biofilms with broad-spectrum activity against both Gram-positive and Gram-negative species. The study population consisted of patients with chronic periprosthetic joint infections (PJIs) of the knee or hip, including both monomicrobial and polymicrobial infections, that are highly resistant to antibiotics due to biofilm formation. TRL1068 was administered via a single pre-surgical intravenous infusion in three sequentially ascending dose groups (6, 15, and 30 mg/kg). Concomitant perioperative antibiotics were pathogen-targeted as prescribed by the treating physician. In this double-blinded study, 4 patients were randomized to receive placebo and 11 patients to receive TRL1068 on day 1, as well as targeted antibiotics for 7 days prior to the scheduled removal of the infected implant and placement of an antibiotic-eluting spacer as the first stage of the standard of care two-stage exchange arthroplasty. No adverse events attributable to TRL1068 were reported. TRL1068 serum half-life was 15-18 days. At day 8, the concentration in synovial fluid was approximately 60% of the blood level and thus at least 15-fold above the threshold for biofilm-disrupting activity in vitro . Explanted prostheses were sonicated to release adherent bacteria for culture, with elimination of the implant bacteria observed in 3 of the 11 patients who received TRL1068, which compares favorably to prior PJI treatments. None of the patients who received TRL1068 had a relapse of the original infection by the end of the study (day 169)., Clinical Trials: This study is registered with ClinicalTrials.gov as NCT04763759., Competing Interests: A.K.-H., E.T., A.L., S.R., L.M.K., and N.M.B. are employees, consultants, and/or stockholders of Trellis Bioscience. J.C., R.E.D., M.A.M., A.S., E.M., E.S., S.I., D.O., R.S., and J.S.A. report no conflicts.

Introduction: There is continued debate regarding the survivorship and revision rate of cementless versus cemented total knee arthroplasty (TKA) prostheses. This includes the assessment of early revision surgery due to aseptic loosenings and periprosthetic joint infections (PJIs). Studies have not always taken into account the impact of comorbidities, such as diabetes, obesity, and tobacco. Therefore, we compared revisions in a large population of patients undergoing cemented or cementless TKAs at 90 days, 1 year, and 2 years., Methods: A review of an administrative claims database was used to identify patients undergoing primary TKA, either cementless (n = 8,890) or cemented (n = 215,460), from October 1, 2015 to October 31, 2020. Revision surgery for PJI and aseptic loosening were identified with diagnosis and associated procedural codes at 90 days, 1 year, and 2 years and then compared between groups. A propensity matched-analysis was performed for age, sex, Charles Comorbidity Index (CCI) > 3, alcohol abuse, tobacco use, obesity, and diabetes. Chi square tests assessed statistical significance of differences in the matched cohorts using odds ratios (ORs) with 95% confidence intervals (CIs). A P < 0.05 was defined as statistically significant., Results: Cementless TKA was associated with similar revisions rates due to PJIs at 90 days (OR, 1.04, 95% CI 0.79-1.38, p = 0.83), 1 year (OR, 0.93, 95% CI 0.75-1.14, p = 0.53, and 2 years (OR, 0.87, 95% CI 0.73-1.05, p = 0.17) in comparison to the cemented TKA cohort. The odds ratio of revision due to aseptic loosening was similar as well at 90 days (OR, 0.67, 95% CI 0.34-1.31, 0.31), 1 year (OR, 1.09, 95% CI 0.73-1.61, p = 0.76), and 2 years (OR, 1.00, 95% CI 0.73-1.61, p = 0.99)., Conclusions: This study found a comparable risk of PJI and aseptic loosening in cementless and cemented TKA when controlling for several comorbidities, such as tobacco, diabetes, and alcohol. Therefore, with proper patient selection, cementless TKAs can be performed with expectation of low risks of infections and aseptic loosenings., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: A consensus has not been reached regarding the optimal timing of elective total knee arthroplasty (TKA) following a stroke. The purpose of this study was to examine the optimal period between stroke and TKA to minimize complications. Specifically, we assessed: (1) medical and surgical complications; (2) timing of stroke and TKA; (3) associated risk factors., Methods: A national database identified 69,815 TKA patients that were separated into 6 exclusive cohorts using a stratum likelihood ratio: no stroke (n = 20,000), stroke within 6 (n = 17,764), 12 (n = 10,338), 18 (n = 8,370), 24 (n = 7,121), and 30 months (n = 6,222) prior to TKA. We analyzed 90-day, 1-year, and 2-year complications in each subgroup. Multivariate analyses were used to identify risk factors for periprosthetic joint infection (PJI)., Results: The multivariate regression model identified that patients with a stroke within 6 months of TKA had increased risk of PJI at all time points (P < .001). Also, stroke 12 to 18 months before TKA elevated PJI risk at 1 and 2 years (all P < .021), while those over 18 months did not show a significant risk compared to controls (P > .067)., Conclusions: Stroke prior to TKA was associated with an increased risk of postoperative complications, specifically PJI. We recommend a minimum of 6 months between stroke and TKA, with 18 months offering the lowest risk., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: While previous research has addressed conversion arthroplasty scenarios, there is limited data on outcomes of staged or concurrent removal of intramedullary (IM) nails during total knee arthroplasty (TKA). Our study aimed to explore the association between the timing of IM nail removal and the incidence of periprosthetic joint infection (PJI), surgical site infection (SSI), manipulation under anesthesia (MUA), and aseptic revision at 90 days, 1 year, and 2 years after TKA when IM nail removal is performed in either a (1) staged or (2) concurrent manner., Methods: We queried a national, all-payer database of all patients who underwent a primary TKA and hardware removal of an IM tibial nail. The group was separated into mutually exclusive cohorts with removal performed either (1) in a staged manner (n = 287) or (2) on the same day of TKA (n = 2,958). Surgical complications included the following: PJIs, SSIs, MUAs, and aseptic revisions. Surgical complications were collected at 90-day, 1 year, and 2-year time points., Results: Patients who had staged nail removal before TKA demonstrated the highest incidence of PJI at 90 days, 1 year, and 2 years (13.9, 16.7, and 17.1%, respectively). Adjusted multivariate regression analyses demonstrated significantly higher odds of a PJI, SSI, and MUA at 90 days, 1 year, and 2 years for all patients who had staged nail removal TKA (P < .001)., Conclusions: There was an observed association between concurrent IM nail removal and a decreased risk of PJI, SSI, and MUA when compared to patients who had nail removal in a staged fashion. However, this does not discount the utility of the staged approach, as it may be necessary for patients less tolerant to longer operative times., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H803).

Introduction: The pleiotropic effects of statins extend beyond managing cardiovascular health and are suggested to modulate Staphylococcus aureus biofilm formation with prosthetic joint infection (PJI) reduction. However, a large analysis of statin use prior to total joint arthroplasty (TJA) to determine infection and revision risk is lacking. We specifically evaluated: 90-day to two-year (1) prosthetic joint infection (PJIs); (2) revisions; and (3) respective risk factors., Materials and Methods: We queried a national, all-payer database for patients undergoing either TKA or THA between 2010-2020. Chronic statin exposure was defined as >3 prescriptions filled within one-year prior to TJA (statin users). A control cohort of patients undergoing TJA without history of statin use prior was identified (statin naïve). Cohorts were matched 1:1 based on demographics and comorbidities (TKA: n=579,136; THA: n=202,092). Multivariate logistic regression was performed to evaluate risk factors for PJIs and revisions., Results: Among TKA recipients, statin users had lower incidence of PJIs at one year (0.36 vs. 0.39%) to two years (0.45 vs. 0.49%) compared to the statin naïve (all, p≤0.007). Similarly, statin users had lower incidence of one- to two-year revisions (all, p≤0.048). Among THA recipients, statin users had lower incidence of PJIs at 90 days (0.37 vs. 0.45%) to two years (2% vs. 2.14%) (all, p<0.001). Similar trends were observed for 90-day to two-year revisions (all, p≤0.022). Statin use was independently associated with decreased odds of PJIs and revisions by one year., Conclusions: Statin use is associated with a reduced risk of PJIs and revisions from one to two years following TJA. It may be worthwhile to ensure patients take statin therapy if indicated for previously established cardiovascular guidelines.

Introduction: Recent coronavirus disease 2019 (COVID-19) infection may pose increased risk of post-operative complications after total joint arthroplasty (TJA). Current recommendations suggest waiting four-weeks before elective surgery in asymptomatic patients. The purpose of this study was to propensity-score-match patients who had positive COVID-19-test between (1) 0-2 weeks and (2) 2-4 weeks before TJA with a matching group without COVID-19 history to determine rates of complications at 90-days and 1-year post-operatively., Materials and Methods: We queried a national-database for patients who tested positively for COVID-19 within 1-month (n = 1749) before TJA. A propensity-score-match analysis was conducted to limit influence of confounders. They were separated into mutually exclusive asymptomatic cohorts based on time of positive COVID-19-test before TJA: within 2-weeks (n = 1749) and between 2-to-4 weeks (n = 599). Asymptomatic patients were patients with positive test without symptoms of fever, shortness of breath, nausea, vomiting, diarrhea, loss of taste or smell, cough, bronchitis, pneumonia, lung infections, septic shock, and multiple-organ-dysfunction. Complications analyzed: 90-day and 1-year periprosthetic-joint infections (PJIs), surgical-site infections(SSIs), wound complications, cardiac complications, transfusions, and venous thromboembolisms., Results: Asymptomatic patients who have COVID-19 demonstrated increased incidence of PJI in patients who had TJA performed within two weeks from positive test at 90-days compared to patients who did not test positive for COVID-19 (3.0 vs. 1.5%; p = 0.023). Upon totaling all 90-day post-operative complications, no significant difference was found amongst asymptomatic patients who tested positive for COVID-19 for total complications at 90-days (p = 0.936)., Conclusions: Asymptomatic patients who test positive for COVID-19 don't have increased risk for post-operative complications after TJA. However, two-fold increased risk in PJI for patients who tested positive for COVID-19 in first 2-weeks cannot be ignored. These results should be taken into consideration when surgeons consider performing TJA. We recommend asymptomatic patients consider waiting two-weeks before TJA to mitigate risk of PJI. Nevertheless, there's reassurance these patients are not at increased total complication risk., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Over ⅓ of the population in the United State is obese (body mass index [BMI] >30 kg/m 2 ), with an increasing proportion being morbidly obese (BMI >40 kg/m 2 ). As the obesity rate climbs, an increasing number have entered the super-obese category (BMI >50 kg/m 2 ), theoretically increasing risk for complications after total hip arthroplasty (THA). This study compared complications in non-obese, obese, morbidly obese, and super-obese patients undergoing THA. We specifically assessed: (1) 1- and 2-year peri-prosthetic joint infection (PJI) rates; (2) complication rates; as well as (3) 1- and 2-year revision rates., Methods: A database review identified patients undergoing primary THA from 01 January 2010 to 31 December 2019. Patients were stratified based on the presence of International Classification of Diseases, 9th and 10th revision diagnosis codes of non-obese (BMI <30 kg/m 2 ) ( n   =  8680), obese (BMI <40 kg/m 2 ) ( n   =  12,443), morbidly obese (BMI <50 kg/m 2 ) ( n   =  5250), and super-obese (BMI >50 kg/m 2 ) ( n   =  814) prior to THA. Complication rates at 90 days, 1 year, and 2 years were compared across groups., Results: At all time points, super-obese patients were associated with higher rates of PJI, even when compared to morbidly obese patients. Complications such as sepsis, venous thrombo-embolism, and revision surgeries were found in higher numbers in super-obese as well as morbidly obese patients, compared to obese and non-obese patients., Conclusions: This study provides large-scale analyses demonstrating the association between super-obese and morbidly obese patients and higher infection rates, as well as complications, following THA. Importantly, the association of PJI is highest among super-obese patients, even when compared to morbidly obese patients. Attaining a BMI <40 kg/m 2 prior to surgery may be an important goal discussed with patients to lower the chance of postoperative infections.

Background: Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures)., Methods: We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated., Results: The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies., Conclusion: The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Incidence of bacteremia following screening colonoscopy is low, but risk of hematogenous spread causing prosthetic joint infection (PJI) may exist in total knee arthroplasty (TKA) patients. In multivariate analyses, we examined PJI risk among 3 TKA cohorts: (1) colonoscopy recipients given antibiotic prophylaxis; (2) colonoscopy recipients not given antibiotic prophylaxis; and (3) no colonoscopy. We assessed 90-day to 1-year (A) PJI risk and (B) risk factors for postcolonoscopy PJI., Methods: We queried a national, all-payer database for primary TKA recipients from 2010 to 2020. Patients who had colonoscopies and who did (n = 2,558) or did not have antibiotic prophylaxis (n = 20,000) were identified. These were compared those who did not undergo colonoscopy (n = 20,000). The 20,000 patients were randomly selected to mitigate type-1 errors. Multivariate regressions compared PJI risk factors, such as alcohol abuse (AA), rheumatoid arthritis (RA), and diabetes., Results: Both colonoscopy cohorts had no increased PJI risk compared to noncolonoscopy (odds ratio (OR) ≤ 2.20, P ≥ .064). Alcohol abuse, diabetes, and RA were found to be risk factors further enhancing likelihood of PJI for TKA patients not receiving antibiotics undergoing colonoscopies (OR ≥ 1.35, P ≤ .044)., Conclusion: Overall, antibiotic prophylaxis does not decrease PJI risk following colonoscopy TKA recipients. After adjusting for known risk factors, both colonoscopy cohorts demonstrated similar PJI risks compared to the noncolonoscopy cohort. However, AA, diabetes, and RA were associated with further increased PJI risk for TKA patients undergoing colonoscopies compared to those who did not. Therefore, if undergoing colonoscopy after TKA, our findings suggest that most patients do not need to have antibiotics except for these high-risk patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Approximately 20,000 patients are diagnosed with septic arthritis annually, with 15% specifically affecting the hip joint. These cases exacerbate arthritic changes, often warranting a total hip arthroplasty (THA). Given their prior history of infection, these patients are predisposed to subsequent periprosthetic joint infections (PJIs). Multiple studies suggest delaying THA after a native septic hip, but no study utilizing a large cohort examined the specific timing to mitigate post-THA PJI risk within a short (<1 year) quiescent period after septic arthritis. We sought to compare patients who were diagnosed with septic hip arthritis at time intervals (0-6, or 6-12 months) prior to an ipsilateral primary THA to a cohort of THA patients who never had a septic hip history. Specifically, we assessed: from 90 days to 2 years (1) revisions due to PJI and (2) associated risk factors for PJI at 2-years., Methods: A national, all-payer database was queried to identify all patients who underwent a primary THA between 2010 and 2021 and patients who had prior ipsilateral septic hip arthritis were characterized using International Classification of Disease and Current Practice Terminology codes (n = 1,052). A randomized sample of patients who never had a history of septic arthritis prior to undergoing THA was used as a nonseptic group comparison (n = 5,000). The incidences of PJI at 90 days through two years were then identified and compared using bivariate chi-square analyses. Risk factors for post-THA PJIs were then analyzed using multivariate regression models., Results: The septic arthritis cohorts were more likely to require revisions due to PJIs, as compared to the non-septic group at 90 days, 1 year, and 2 years (all P < .0001). Patients who were diagnosed with septic arthritis between 0 and 6 months prior to THA were at greater PJI risk at both one-year (odds ratio (OR) of 43.1 versus 29.6, P < .0001) and two years (OR of 38.3 versus 22.1, P < .0001) compared to patients who had diagnoses between 6 and 12 months. Diabetes mellitus, obesity, and tobacco use were associated risk factors for PJIs at 2 years in the septic hip cohort in comparison to the cohort without a septic hip history., Conclusion: Less than a 1-year quiescent period after septic arthritis is associated with a 38 times increased risk and a 22 times risk for post-THA PJI, at 0 and 6 months and 6 and 12 months, respectively. Though patients who undergo THA greater than 6 months after their septic arthritis treatment have a decreased risk compared to those between 0 and 6 months the risks are still high. Orthopaedic surgeons should be aware of the increased risks of PJIs when considering performing a THA in patients with a history of septic arthritis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: A prior history of a septic knee may predispose patients to a periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). We performed multivariate analyses of known risk factors that portend a periprosthetic infection for patients who have a history of septic arthritis (SA). The focus of the study was an assessment of the incidence of TKA PJIs at various time intervals after the onset of a septic knee (0 to 3 months, 3 to 6 months, 6 to 9 months, and 9 months to 1-year)., Methods: We queried a national database to identify patients who underwent a primary TKA between 2010 and 2021 (n = 1.9 million). Patients who had a prior septic knee ipsilateral to the primary TKA were characterized (n = 4,251) and were put into four specific cohorts based on the interval between the SA diagnosis and TKA: less than 3 months; 3 to 6 months; 6 to 9 months; and 9 to 12 months. A cohort of patients who did not have history of septic knee were used for comparison (n = 5,000). The incidence of PJIs from 90 days to 1 year was identified and compared using multivariate analyses., Results: All time cohorts were more likely to require revisions due to PJI, as compared to the comparison group. Significant differences were demonstrated among all time cohorts who had prior SA compared to patients who did not have a history of SA (odds ratio [OR] range, 90.0 to 113.0, P < .001)., Conclusion: This study has shown an increased PJI risk in the first year after SA (P < .05). The surgeon should be aware of the increased PJI risk after SA within the first year after TKA., (Copyright © 2022 Elsevier Inc. All rights reserved.)

To our knowledge, no studies have compared postoperative outcomes between patients who received a temporary short or long intramedullary (IM) nail in the setting of infected total knee arthroplasty (TKA). Therefore, the aim of this study was to compare short-term outcomes for patients who underwent long or short IM nail insertion for treatment of periprosthetic knee infection. Specifically, we compared: (1) success rates; (2) patient reported/functional outcomes; and (3) complications between patients implanted with a short or a long IM nail following PJI of the knee. A retrospective chart review was performed for patients who underwent two-stage exchange arthroplasty with a temporary long or short IM nail between November 2010 and June 2018 at our institution ( n  = 67). Continuous and categorical variables were assessed using t -test/Mann-Whitney U test and chi-squared test, respectively. Logistic regression analyses were conducted to assess the effect of IM nail length on success rate while adjusting for age, sex, body mass index, and race. A total of 36 patients underwent temporary treatment with a long IM nail, while 31 patients received a short IM nail. There were no differences in success rate for reimplanted patients treated with long and short IM nails (odds ratio 0.992; p  = 0.847). Fewer patients with a long IM nail went on to reimplantation (52.8 vs. 83.9%; p  = 0.007). There was no difference in satisfaction (7.86 vs. 7.68; p  = 0.515), pain scores (3.39 vs. 4.45 points; p  = 0.126), or Knee Society score outcome scores (150.61 vs. 166.26 points; p  = 0.117) between long or short IM nail patients. Following reimplantation, there was no difference in the number of patients who became reinfected (15.8 vs. 11.5%; p  = 0.679) or went on to amputation (0 vs. 7.7%; p  = 0.210). Periprosthetic joint infection (PJI) is a rare but serious postoperative complication following TKA. Our findings suggest that the use of long and short IM nails during two-stage exchange can have equal utility in PJI patients with severe bone defects., Competing Interests: J.D.C. reports personal fees from Biocomposities, personal fees from Bonesupport, personal fees from DePuy Synthes, personal fees from MHE Coalition, personal fees from Orthofix, Inc, personal fees from OrthoPediatrics, personal fees from Pega Medical, personal fees from Smith and Nephew, personal fees from Stryker, personal fees from University of Florida, personal fees from Zimmer, personal fees from Zimmer Biomet, outside the submitted work. R.E.D. reports other from Flexion Therapeutics, other from Orthofix Inc, other from Stryker Corp, other from United Orthopedics Corp, other from Tissue Gene, outside the submitted work. R.E.D. reports other from Flexion Therapeutics, other from Orthofix Inc, other from Stryker Corp, other from United Orthopedics Corp, other from Tissue Gene, outside the submitted work. F.J.P. reports other from Biocomposites Inc., personal fees from Total Joint Orthopedics, personal fees and other from VisualDx, outside the submitted work., (Thieme. All rights reserved.)

Introduction: Periprosthetic joint infection (PJI) affects many revision total hip arthroplasty (THA) patients, contributing to a concomitant rise in revision costs. Means of decreasing the risk of PJI include the use of antibiotic adjuncts, such as calcium sulphate beads (CSBs). Mixed with antibiotics, the potential benefits of CSBs include dissolvability and antibiotic drug elution. However, information comparing them in aseptic revision is scarce. Therefore, this study investigated CSB utilisation for infection prevention in aseptic revision THA. Specifically, we compared (1) infection rates; (2) lengths of stay; (3) subsequent infection procedures; and (4) final surgical outcome in 1-stage aseptic revision THA patients who did received CSBs to 1-stage aseptic revision THA patients who did not., Methods: A retrospective chart review was performed to identify all patients who underwent an aseptic revision THA between January 2013 and December 2017. Patients who received CSBs ( n = 48) were compared to non-CSB patients ( n = 58) on the following outcomes: postoperative infections, lengths of stay (LOS), subsequent irrigation and debridements (I+Ds), and final surgical outcome, classified as successful THA reimplantation, retained antibiotic spacer, or Girdlestone procedure. Chi-square and t -testing were used to analyse the variables., Results: There was no significant differences found between CSB patients and non-CSB patients in postoperative infections ( p = 0.082), LOS ( p = 0.179), I+Ds ( p = 0.068), and final surgical outcome ( p = 0.211)., Conclusion: This study did not find any statistical difference between CSBs and standard of care in infection rates and surgical outcomes. The advantage of these beads for 1-stage aseptic revisions is questionable.

Background: Traditional management of prosthetic joint infection following total knee arthroplasty (TKA) consists of a 2-stage approach. However, 1.5-stage exchange has seen preliminary success, whereby metal femoral and all-polyethylene tibia components are placed without intention for subsequent second stage. We sought to examine all patients who underwent a 1.5-stage exchange TKA at a single institution compared to historical 2-stage controls. We assessed the following: (1) infection-free survivorship and risk factors for reinfection; (2) 1-year surgical/medical outcomes; (3) patient-reported outcomes (ie, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS JR]); and (4) radiographic outcomes., Methods: We reviewed all patients undergoing a 1.5-stage (between 2015 and 2019) and 2-stage exchange TKA (between 2011 and 2016) at a single institution. A total of 162 knees were included (1.5-stage: 114; 2-stage: 48) with mean clinical follow-up of 2.6 years. KOOS JR scores and radiographic outcomes were evaluated at last clinical follow-up., Results: The 1.5-stage exchange TKA resulted in a 10.1% difference in infection-free survival (85.1% vs 75.0%, P = .158), compared to 2-stage exchange. Prior prosthetic joint infection was found to be an independent risk factor for reinfection (P = .030). Overall, postoperative complications were lower among 1.5-stage exchanges (8.8% vs 31.3%, P < .001). KOOS JR scores improved more from baseline among 1.5-staged (Δ24.7 vs Δ16.6, P < .001). Radiographic review did not demonstrate any progressive radiolucent lines, subsidences, or failures in either group., Conclusion: A 1.5-stage exchange TKA is an effective alternative to the traditional 2-stage protocols with noninferior infection eradication and absence of radiographic complications at over 2 years of mean follow-up., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA) are serious orthopaedic complications that pose marked burdens to both patients and health care systems. At our institution, two-stage exchange with a temporary short antibiotic cement-coated intramedullary nail was utilized for the treatment of repeat PJIs in a series of compromised patients with considerable bone loss. This study reports on (1) success rates, (2) functional and pain outcomes, (3) and complications for patients receiving a temporary short intramedullary nail for the treatment of PJI. Our institutional database was queried for all repeat knee PJI patients between March 1st, 2009 and February 28th, 2015. Patients with type II/III Anderson Orthopaedic Research Institute (AORI) bone defects who underwent two-stage exchange arthroplasty with a short antibiotic-coated intramedullary nail were included for analysis ( n  = 31). Treatment success was determined using the Delphi-based consensus definition of a successfully treated PJI: infection eradication (healed wound with no recurrence of infection by the same organism), no further surgical intervention for infection after reimplantation, and no PJI-related mortality. A paired t -test was performed to assess for continuous variables. A total of 26 patients went on to reimplantation, while 5 patients retained the intramedullary nail. Overall treatment success was 74.2%. Range of motion significantly decreased postoperatively (102.1 vs. 87.3 degrees; p  < 0.001), while Knee Society Scores (function) significantly increased (55.6 vs. 77.7, p  < 0.001). A majority of patients were full weight-bearing immediately following surgery (38.7%). Treating poor health status patients with PJI of the knee can be difficult after multiple revisions. With a success rate similar to conventional methods, our results demonstrate that two-stage exchange with a temporary short intramedullary nail may be a desirable treatment option for patients with bony defects wishing to avoid amputation or permanent arthrodesis. However, this method does not outperform other treatment modalities, and may not be suitable for all patients. Patient expectations and health status should be carefully assessed to determine if this procedure is appropriate in this complex patient population., Competing Interests: R.E.D. reports other from Baltimore City Medical Society, other from Orthofix, Inc, other from Stryker, other from United Orthopedics, other from Flexion Therapeutics, other from TissueGene, outside the submitted work. M.A.M. reports personal fees and other from Peerwell, other from USMI, personal fees from Cymedica, personal fees and other from DJ Orthopaedics, personal fees from Flexion Therapeutics, personal fees and other from Johnson & Johnson, personal fees and other from Ongoing Care Solutions, personal fees and other from Orthosensor, personal fees from Pacira, personal fees from Performance Dynamics Inc, personal fees from Pfizer, personal fees from Skye Biologics, personal fees and other from Stryker, personal fees and other from TissueGene, other from National Institute of Health (NIAMS & NICHD), outside the submitted work; In addition, M.A.M. has a patent Microport with royalties paid, a patent Stryker with royalties paid, a patent Medicus Works LLC with royalties paid, a patent Up-To-Date with royalties paid, and a patent Wolters-Kluwer Health - Lippincott Williams & Wilkins with royalties paid and Editorial or Governing Board: Journal of Arthroplasty; Journal of Knee Society; Orthopedics; Surgical Techniques International; Board/Committee Member: American Academy of Orthopaedic Surgery; American Association of Hip and Knee Surgeons; Knee Society. All the other authors report no conflict of interest., (Thieme. All rights reserved.)

Background: With the increased demand for primary total hip arthroplasty (THA) and corresponding rise in revision procedures, it is imperative to understand the factors contributing to the development of Clostridium difficile colitis. We aimed to provide a detailed analysis of: (1) the incidence of; (2) the demographics, lengths of stay, and total costs for; and (3) the risk factors and mortality associated with the development of C. difficile colitis after revision THA., Methods: The National Inpatient Sample database was queried for all individuals diagnosed with a periprosthetic joint infection and who underwent all-component revision THA between 2009 and 2013 (n = 40,876). Patients who developed C. difficile colitis during their inpatient hospital stay were identified. Multilevel logistic regression analysis was conducted to assess the association between hospital- and patient-specific characteristics and the development of C. difficile colitis., Results: The overall incidence of C. difficile colitis after revision THA was 1.7%. These patients were significantly older (74 vs 65 years), had greater lengths of hospital stay (19 vs 9 days), accumulated greater costs ($51,641 vs $28,282), and were more often treated in an urban hospital compared to their counterparts who did not develop C. difficile colitis (P < .001 for all). Patients with colitis also had a significantly higher in-hospital mortality compared to those without (5.6% vs 1.4%; P < .001)., Conclusion: While C. difficile colitis infection is an uncommon event following revision THA, it can have potentially devastating consequences. Our analysis demonstrates that this infection is associated with a longer hospital stay, higher costs, and greater in-hospital mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The diagnosis of periprosthetic hip infections is often challenging. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level blood laboratory tests are commonly used to aid in the diagnosis. We studied the sensitivity, specificity, and false-negative rates of ESR and CRP level in a prospective group of patients who underwent revision total hip arthroplasty between 2000 and 2008. Seventy-seven patients with periprosthetic hip infections and ESR and CRP data were identified. Chi-square analysis was performed to determine the significance of false-negatives, compared with sex, body mass index, primary diagnosis, infection type, and immunity status. ESR had 89% sensitivity and 69% specificity. CRP level had 93% sensitivity and 40% specificity. The false-negative rate was 10.8% for ESR and 7% for CRP level. The false-negative rate for ESR and CRP level combined (with either result positive) was 3%. All false-negatives in the combined group were immunocompromised. Chi-square analysis did not find a significant correlation between false-negatives and any other variables. ESR and CRP level are useful in the diagnosis of periprosthetic hip infections. Ordering these tests concurrently reduces the chance of false-negative results.

Surgical site infections following elective knee arthroplasties occur most commonly as a result of colonisation by the patient's native skin flora. The purpose of this study was to evaluate the incidence of deep surgical site infections in knee arthroplasty patients who used an advance cutaneous disinfection protocol and who were compared to patients who had peri-operative preparation only. All adult reconstruction surgeons at a single institution were approached to voluntarily provide patients with chlorhexidine gluconate-impregnated cloths and a printed sheet instructing their use the night before and morning of surgery. Records for all knee arthroplasties performed between January 2007 and December 2008 were reviewed to determine the incidence of deep incisional and periprosthetic surgical site infections. Overall, the advance pre-operative protocol was used in 136 of 912 total knee arthroplasties (15%). A lower incidence of surgical site infection was found in patients who used the advance cutaneous preparation protocol as compared to patients who used the in-hospital protocol alone. These findings were maintained when patients were stratified by surgical infection risk category. No surgical site infections occurred in the 136 patients who completed the protocol as compared to 21 infections in 711 procedures (3.0%) performed in patients who did not. Patient-directed skin disinfection using chlorhexidine gluconate-impregnated cloths the evening before, and the morning of, elective knee arthroplasty appeared to effectively reduce the incidence of surgical site infection when compared to patients who underwent in-hospital skin preparation only.

The purpose of this study was to evaluate effectiveness of an advance, at-home chlorhexidine-impregnated skin preparation cloth in decreasing the incidence of deep periprosthetic hip arthroplasty infections. Arthroplasty surgeons at the senior author's institution provided their patients with chlorhexidine-impregnated single-use cloths for use at home the night before and the morning of surgery. Between January 2007 and December 2009, the compliance of this practice, as well as the incidence of periprosthetic infections, was monitored for all patients who underwent hip arthroplasty. Of the 1134 patients who underwent hip arthroplasty, 157 patients completely complied with the preoperative chlorhexidine preparation protocol. There were 14 infections in the group that was not compliant (1.6% infection rate), and there were no infections in the compliant patient population. Based on the results of this study, at-home preoperative patient skin preparation appears to be a simple and cost-effective method to reduce periprosthetic hip infection rates., (Copyright 2010. Published by Elsevier Inc.)