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Prosthetic Joint Infection (PJI) is a significant healthcare issue affecting 1%−2% of patients undergoing prosthetic surgery, leading to high mortality rates and substantial healthcare costs. The main challenge in combating PJI is the microorganisms' ability to form biofilms, which are highly resistant to antibiotics and the immune system. Recent research focuses on new diagnostic and treatment strategies, such as genomic analysis of bacteria, biomarkers in synovial fluid, and serum protein electrophoresis. Additionally, studies explore biofilm-active drugs, alternative antibiotic regimens, and novel antiseptic solutions for PJI treatment and prevention. [Extracted from the article]

Prosthetic joint infections (PJIs) can have disastrous consequences for patient health, including removal of the device, and placement of cemented implants is often required during surgery to eradicate PJIs. In translational research, in vivo models are widely used to assess the biocompatibility and antimicrobial efficacy of antimicrobial coatings and compounds. Here, we aim to utilize Galleria mellonella implant infection models to assess the antimicrobial activity of antibiotic-loaded bone cement (ALBC) implants. Therefore, we used commercially available bone cement loaded with either gentamicin alone (PALACOS R+G) or with a combination of gentamicin and vancomycin (COPAL G+V), compared to bone cement without antibiotics (PALACOS R). Firstly, the in vitro antimicrobial activity of ALBC was determined against Staphylococcus aureus. Next, the efficacy of ALBC implants was analyzed in both the G. mellonella hematogenous and early-stage biofilm implant infection model, by monitoring the survival of larvae over time. After 24 h, the number of bacteria on the implant surface and in the tissue was determined. Larvae receiving dual-loaded COPAL G+V implants showed higher survival rates compared to implants loaded with only gentamicin (PALACOS R+G) and the control implants without antibiotics (PALACOS R). In conclusion, G. mellonella larvae infection models with antibiotic-loaded bone cements are an excellent option to study (novel) antimicrobial approaches.

Robinsoniella peoriensis is a Gram-positive, strictly anaerobic, spore-forming, rod-shaped bacterium belonging to the phylum Firmicutes and the family Lachnospiraceae. Until now, R. peoriensis is the only species of its genus. It was first isolated in 2003 during a study into the flora of lagoons and manure pits. Given the rarity of this microorganism and the sparse information in the literature about its way of transmission, the way to diagnose its infections and identify it in the microbiology laboratory, and its public health relevance, the present study aimed to identify all the published cases of Robinsoniella, describe the epidemiological, clinical, and microbiological characteristics, and provide information about its antimicrobial resistance, treatment, and outcomes. A narrative review was performed based on a Pubmed/Medline and Scopus databases search. In total, 14 studies provided data on 17 patients with infections by Robinsoniella. The median age of patients was 63 years and 47% were male. The most common types of infection were bone and joint infections, bacteremia, infective endocarditis, and peritonitis. The only isolated species was R. peoriensis, and antimicrobial resistance to clindamycin was 50%, but was 0% to the combination of piperacillin with tazobactam, aminopenicillin with a beta-lactamase inhibitor, and metronidazole which were the most commonly used antimicrobials for the treatment of these infections. The overall mortality depends on the type of infection and is notable only for bacteremia, while all other infections had an optimal outcome. Future studies should better assess these infections’ clinical and epidemiological characteristics and the mechanisms of the antimicrobial resistance of this microorganism from a mechanistic and genetic perspective.

Prosthetic joint infection (PJI) is one of the most serious complications of joint replacement surgery among orthopedic surgeries and occurs in 1 to 2% of primary surgeries. Additionally, the cause of PJIs is mostly bacteria from the Staphylococcus species, accounting for more than 98%, while fungi cause PJIs in only 1 to 2% of cases and can be difficult to manage. The current gold-standard microbiological method of culturing synovial fluid is time-consuming and produces false-negative and -positive results. This study aimed to identify a novel, accurate, and convenient molecular diagnostic method. The DreamDX primer–hydrolysis probe set was designed for the pan-bacterial and pan-fungal detection of DNA from pathogens that cause PJIs. The sensitivity and specificity of DreamDX primer–hydrolysis probes were 88.89% (95% CI, 56.50–99.43%) and 97.62% (95% CI, 87.68–99.88%), respectively, compared with the microbiological method of culturing synovial fluid, and receiver operating characteristic (ROC) area under the curve (AUC) was 0.9974 (*** p < 0.0001). It could be concluded that the DreamDX primer–hydrolysis probes have outstanding potential as a molecular diagnostic method for identifying the causative agents of PJIs, and that host inflammatory markers are useful as adjuvants in the diagnosis of PJIs.

Background and Objectives: Despite the promise of phage therapy (PT), its efficacy in prosthetic joint infection (PJI) management is unknown. Much of the current literature is largely limited to case reports and series. Materials and Methods: In order to help inform power calculations for future clinical trials and comparative analyses, we performed a systematic review and proportional meta-analysis of early PT outcomes to provide a preliminary assessment of early phage therapy treatment outcomes for cases of PJI. Results: In a search of available literature across MEDLINE (Ovid, Wolters Kluwer, Alphen aan den Rijn, The Netherlands), Embase (Elsevier, Amsterdam, The Netherlands), the Web of Science Core Collection (Clarivate, London, UK), and Cochrane Central (Wiley, Hoboken, NJ, USA) up to 23 September 2023, we identified 37 patients with PJIs receiving adjunctive PT. Patients most frequently reported Staphylococcal species infection (95%) and intraarticular phage delivery (73%). Phage cocktail (65%) and antibiotic co-administration (97%) were common. A random-effects proportional meta-analysis suggested infection remission in 78% of patients (95% CI: 39%, 95%) (I2 = 55%, p = 0.08) and 83% with a minimum 12-month follow-up (95% CI: 53%, 95%) (I2 = 26%, p = 0.26). Conclusions: Our study provides a preliminary estimate of PT’s efficacy in PJIs and informs future comparative studies.

It has been suggested that targeted therapy may potentially increase the risk of listeriosis. However, no reported cases of Listeria monocytogenes prosthetic joint infection have been documented during Janus Kinase (JAK) pathway inhibitor use. Herein, we present a 70-year-old female with rheumatoid arthritis who had undergone bilateral hip joint replacement and subsequently developed Listeria monocytogenes prosthetic joint infection following tofacitinib therapy. We suggest that the use of tofacitinib may potentially heighten susceptibility to listeriosis in patients afflicted with rheumatoid arthritis.

Background: With the increasing number of total hip arthroplasties performed across the world, there is a noted rise in the number of prosthetic joint infections. Two-staged revisions are the most accepted interventions for these. There are two forms of interim antibiotic spacers - hand-made and prefabricated. There is paucity of long-term data to support the use of the latter. The purpose of our retrospective study was to analyse the long-term results of the same. Methods: Out of 45 patients treated by two-staged revision for prosthetic hip joint infections, 31 underwent implantation of prefabricated antibiotic-loaded spacer in the first stage (June 2011–October 2020). The primary objective was to determine the recurrence rate of infection, and secondary objectives were analysis of outcome, time for infection eradication, and review of complications encountered. Minimal follow-up was 1 year and maximum was 8 years (mean 48.02 months). Results: 29 patients underwent both the stages of the revision procedure. None had infection recurrence. 2 died before the second stage. Long term (5 years) mortality was 8.6 %. Mean interval between the 1st and 2nd stage surgeries was 16.5 weeks. 2 patients had spacer dislocations; one required an open reduction. 1 patient had a fracture during the 2nd stage, and 3 had dislocations after the 2nd stage. Conclusion: Prefabricated antibiotic loaded spacer remains a promising option in dealing with prosthetic hip joint infections. Our experience and long-term follow-up results depicts low complication rate of the procedure whilst facilitating long-term infection control and nil infection recurrence rate.

Microbiological diagnosis of osteoarticular infections (OI) is crucial for a successful treatment. A prospective multicenter study including 262 synovial fluids with suspicion of acute OI was performed between July 2021 and October of 2022. BioFire Joint Infection Panel multiplex-PCR test was performed and results were compared with conventional cultures of synovial fluid specimens. In total, 136 microorganisms were detected, and fourteen samples were positive for more than one microorganism. In monomicrobial infections (n = 87) agreement with culture was 69%. In 26 samples, the multiplex PCR yield an additional positive result when culture result was negative. It helped in the detection of fastidious microorganisms as K. kingae and N. gonorrhoeae. This multiplex PCR has proven to be a useful technique that can be used for patients with high suspicion of acute OI in a rapid and automated manner.

Background: Dalbavancin is a lipoglycopeptide antibiotic approved for treatment of skin and soft tissue infections, administered as a single or two-dose treatment. The extended half-life, good penetration into bone and synovial fluid, and bactericidal activity against gram-positive bacteria, including those in biofilm, make dalbavancin an appealing choice for treatment of bone and joint infections in outpatient settings. However, we present a rare case of ototoxicity associated with off-label extended dalbavancin treatment of a prosthetic joint infection. Case presentation: A 55-year-old man with a prosthetic joint infection of the shoulder underwent off-label extended dalbavancin treatment, receiving a cumulative dose of 2500 mg. The patient experienced a gradual onset of hearing loss following the first dose, leading to a diagnosis of bilateral sensorineural hearing loss that persisted 1 year after dalbavancin was discontinued. Conclusions: This case report highlights the importance of exercising caution when administering dalbavancin beyond approved dosing guidelines, and emphasizes the need for vigilance regarding the potential for ototoxicity. [ABSTRACT FROM AUTHOR]

Bone and joint infections (BJI) require prolonged antimicrobial treatment, leading to lengthy hospitalizations, high costs, the risk of nosocomial infections, and the development of antimicrobial resistance. Dalbavancin is a novel semisynthetic lipoglycopeptide approved for the treatment of adults and children with acute bacterial skin and skin structure infections. This narrative review aims to summarize the characteristics of dalbavancin and the current scientific evidence regarding its clinical efficacy and safety in the treatment of BJI. A literature search until June 2023 was performed to identify all published research about the role of dalbavancin in the management of BJI. Due to its unique pharmacokinetics characterized by prolonged half-life, high bactericidal activity against most Gram-positive bacteria, a good safety profile, and high tissue penetration, dalbavancin can be a valuable alternative to the treatment of BJI. Clinical studies have shown its non-inferiority compared to conventional therapies in BJI, offering potent activity against key pathogens and an extended dosing interval that may shorten hospitalization. In conclusion, dalbavancin represents a promising treatment option for BJI with a favorable safety profile, but further research in both adults and particularly children, who are ideal candidates for long-acting antibiotics, is necessary to evaluate the role of dalbavancin in BJI. [ABSTRACT FROM AUTHOR]

Replacement of native joints aims to restore patients' quality of life by relieving pain and improving joint function. While periprosthetic joint infection (PJI) affects a small percentage of patients, with an estimated incidence of 1–9% following primary total joint replacement, this postoperative complication necessitates a lengthy hospitalisation, extended antibiotic treatment and further surgery. It is highlighted that establishing the correct diagnosis of periprosthetic infections is critical in order for clinicians to avoid unnecessary treatments in patients with aseptic failure. Of note, the PJI diagnosis could not purely rely upon clinical manifestations given the fact that heterogeneity in host factors (e.g., age and comorbidities), variability in infection period, difference in anatomical location of the involved joint and discrepancies in pathogenicity/virulence of the causative organisms may confound the clinical picture. Furthermore, intra-operative contamination is considered to be the main culprit that can result in early or delayed infection, with the hematogenous spread being the most prevalent mode. To elaborate, early and hematogenous infections often start suddenly, whereas chronic late infections are induced by less virulent bacteria and tend to manifest in a more quiescent manner. Last but not least, viruses and fungal microorganisms exert a role in PJI pathogenesis. [ABSTRACT FROM AUTHOR]

This article provides an updated review of guidelines and clinical studies on dental antibiotic prophylaxis in total joint replacement. The review found that there is no significant benefit of antibiotic prophylaxis in reducing the risk of prosthetic joint infections (PJI) following dental procedures. Routine activities like chewing and brushing were found to contribute more to bacteremia and potential joint infection than dental procedures themselves. The study concludes that antibiotic prophylaxis for dental procedures in patients with joint prostheses is not universally beneficial and should not be routinely recommended. Instead, emphasis should be placed on individual risk assessment, good oral hygiene, and adherence to evidence-based guidelines. Another systematic review of multiple studies found no increased risk of PJI following dental procedures in patients with hip or knee replacements. The use of prophylactic antibiotics also did not show a significant association with the incidence of PJI. Maintaining good oral hygiene and regular dental assessments were found to reduce the risk of PJI by at least 30%. The review suggests that current policies on antibiotic prophylaxis for patients with joint replacements undergoing dental treatment should be reconsidered. Several studies were reviewed to assess the evidence supporting the use of prophylactic antibiotics. The studies found no direct evidence to support the use of antibiotics prior to dental procedures in patients with prosthetic joints. The authors recommend against routine antibiotic prophylaxis, as it is not cost-effective and contributes to antibiotic resistance. However, maintaining good oral hygiene is important to prevent a small number of infections associated with oral [Extracted from the article]

The utility of α-defensin (AD), leukocyte esterase (LE) levels, and metagenomics sequencing as diagnostic tools for prosthetic joint infection (PJI) has been suggested, but there are few studies among the Asian population. This study aimed to evaluate the diagnostic performance of various biomarkers for PJI and the role of the microbiome in the synovial fluid of patients with prostheses. Patients with suspected knee PJI were enrolled, and their blood and synovial fluid were collected. The cases were classified into the PJI and non-PJI groups. Significant differences between the two groups were observed in the levels of AD (4698 µg/L vs. 296 µg/L, p < 0.001) and positivity for LE (62.5% vs. 21.1%, p = 0.01). AD had 94.4% sensitivity and 89.5% specificity for diagnosing PJI, whereas LE had 37.5% sensitivity and 100% specificity. Microbiome taxonomic profiling showed high sensitivity. The number of operational taxonomic units and the richness of the microbiome in the synovial fluid were higher in the non-PJI than in the PJI group. AD has shown encouraging results in the Asian population as a diagnostic biomarker for PJI, and LE can be used as a diagnostic adjunct. The bacterial richness of the synovial fluid is likely associated with infections. [ABSTRACT FROM AUTHOR]

Purpose: To identify clinical and laboratory predictors for low- and high-grade prosthetic joint infection (PJI) within the first postoperative days following primary total hip/knee arthroplasty (THA/TKA). Methods: Institutional bone and joint infection registry of a single osteoarticular infection referral centre was reviewed to identify all osteoarticular infections treated between 2011 and 2021. Among them were 152 consecutive PJI (63 acute high-grade PJI, 57 chronic high-grade PJI, and 32 low-grade PJI) who also had primary THA/TKA performed at the same institution, which were retrospectively analyzed with multivariate logistic regression and covariables. Results: For each additional day of wound discharge, persistent wound drainage (PWD) predicted PJI in the acute high-grade PJI group with odds ratio (OR) 39.4 (p = 0.000, 95%CI 1.171–1.661), in the low-grade PJI group with OR 26.0 (p = 0.045, 95%CI 1.005–1.579), but not in the chronic high-grade PJI group (OR 16.6, p = 0.142, 95%CI 0.950–1.432). The leukocyte count product of pre-surgery and POD2 >100 predicted PJI in the acute high-grade PJI group (OR 2.1, p = 0.025, 95%CI 1.003–1.039) and in the chronic high-grade PJI group (OR 2.0, p = 0.018, 95%CI 1.003–1.036). Similar trend was also seen in the low-grade PJI group, but was not statistically significant (OR 2.3, p = 0.061, 95%CI 0.999–1.048). Conclusions: The most optimal threshold value for predicting PJI was observed only in the acute high-grade PJI group, where PWD >three days after index surgery yielded 62.9% sensitivity and 90.6% specificity, whereby the leukocyte count product of pre-surgery and POD2 >100 showed 96.9% specificity. Glucose, erythrocytes, hemoglobin, thrombocytes, and CRP showed no significant value in this regard. [ABSTRACT FROM AUTHOR]

Background: Current nasal decolonization strategies utilize pre-operative agents without consideration for short-term re-colonization or de novo colonization. Many strategies utilize an antibiotic-based agent, raising concerns of limited gram-negative antimicrobial coverage and the emergence of resistant bacterial strains. This study evaluated the clinical utility of a non-antibiotic, alcohol-based nasal decolonization agent in decreasing surgical site infection (SSI) rates after total joint arthroplasty. Patients and Methods: We retrospectively compared an 18-month cohort of elective primary total joint arthroplasty patients treated peri-operatively with an alcohol-based sanitizer to historical controls. The alcohol-based agent was administered pre-operatively the day of surgery and for two weeks after surgery. Patients were followed for 90 days and assessed for signs or symptoms of SSI. Patient and caregiver compliance was recorded. There were 779 patients included in the experimental group and 647 included in the historical control group. Results: Patients receiving alcohol-based nasal decolonization had a lower rate of SSI compared with controls not receiving nasal decolonization (0.64% [5/779] vs. 1.55% [10/647]; p = 0.048; odds ratio, 2.43). Utilization of an alcohol-based nasal sanitizer in the pre-operative and prolonged post-operative setting decreased infection rates by 41.3% in our elective total joint arthroplasty setting. Conclusions: When used pre- and post-operatively, alcohol-based nasal decolonization of bacteria in patients undergoing total joint arthroplasty led to a substantial decrease in SSIs. [ABSTRACT FROM AUTHOR]

Total hip arthroplasty (THA) has been one of the most successful surgical interventions in recent memory and is nicknamed by some the "Surgery of the Century". Over the past decade, there has been a drastic change in THA management with the rise of the direct anterior approach both globally and in the USA market. While many would remark that this has been driven by false marketing, it is clear that the direct anterior approach can be an effective and safe way to perform a THA. It is the goal of this review to highlight evidence of its outcomes and clinical advantages, in particular, how it can decrease dislocation, even in high-risk individuals, and result in faster recovery in the early postoperative period with decreased muscular inflammation. We will also highlight its major disadvantages, including but not limited to increased wound complications and risk for periprosthetic fracture. Hopefully, this review will provide up-to-date information on the current state of the direct anterior approach and provide recommendations on patients that would be optimal candidates for this technique. [ABSTRACT FROM AUTHOR]

A meta‐analysis study to assess the knee and hip arthroplasty joint surgical site wound infection (SSWI) in end‐stage renal disease (ESRD) subjects who underwent dialysis or a kidney transplant (KT). A comprehensive literature examination till February 2023 was implemented and 1046 linked studies were appraised. The picked studies contained 5 471 898 subjects with total joint arthroplasty (TJA) at the baseline, 13 049 of them were haemodialysis or renal transplant, and 5 458 849 were control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of knee and hip arthroplasty SSWI in ESRD subjects who underwent dialysis or a KT by the dichotomous and continuous styles and a fixed or random model. Haemodialysis or renal transplant had a significantly higher postoperative SSWI (OR, 2.13; 95% CI, 1.73–2.62, P <.001) compared with control in TJA subjects. However, no significant difference was observed between haemodialysis and renal transplant in postoperative SSWI (OR, 0.93; 95% CI, 0.16–5.54, P =.94) and between haemodialysis or renal transplant and control in prosthetic joint infection (OR, 1.07; 95% CI, 0.25–4.55, P =.93) in TJA subjects. Haemodialysis had a significantly higher prosthetic joint infection (OR, 1.92; 95% CI, 1.21–3.03, P =.005) compared with renal transplant in TJA subjects. Haemodialysis or renal transplant had a significantly higher postoperative SSWI in TJA subjects. Also, haemodialysis had a significantly higher prosthetic joint infection compared with renal transplant in TJA subjects. Although precautions should be taken when commerce with the consequences because a low number of selected studies was picked for certain comparisons in this meta‐analysis. [ABSTRACT FROM AUTHOR]

Background: Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favourable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing debridement, antibiotics and implant retention (DAIR). Methods: We reviewed medical records and microbiology reports of 67 patients (37 males and 30 females) undergoing DAIR due to PJI between 2014 and 2021. Patient-related factors, co-morbidities and microbiological reports were collected and reviewed. Forty-four patients had hip, 21 had knee, 1 had shoulder and 1 had elbow joint infection. Obtained data were statistically analysed with a logistic regression model. Results: Rifampicin-sensitive organism was isolated in 47 cases. Recovery rate was 72.3% in the sensitive and 76.9% in the resistant group. We found no significant effect of rifampicin resistance on the probability of recovery. Age and diabetes mellitus showed negative clinical impact on recovery. Staphylococcus aureus and coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (66.6% of the isolates) and Gram-negative rods in the resistant group (65.2%). Conclusions: Based on our results, higher age and diabetes mellitus may have a clinically relevant negative impact on clinical outcome, however, this effect was not statistically significant. This may be due to the limited number of patients included in this study. We observed no clinically relevant effect of rifampicin-resistance, sex and body mass index (BMI) on recovery rates among patients undergoing DAIR due to PJI. [ABSTRACT FROM AUTHOR]

Background: Accurate diagnosis of prosthetic joint infection (PJI) enables early and effective treatment. However, there is currently no gold standard test for microbial detection of PJI and traditional synovial fluid culture is relatively insensitive. Recently, it has been reported that sonicating fluid culture and next-generation sequencing (NGS) improve microbial detection rates. Hence, we performed a systematic review and meta-analysis to compare microbial detection rates in microbial culture methods with and without sonication versus NGS. Methods: We systematically searched EMBASE, PubMed, Scopus, CINAHL, and Ichushi databases and other sources (previous reviews) until August 2022. We evaluated the detection rates of pathogens in NGS and microbial cultures using samples of synovial or sonicated fluid. Results: Of the 170 citations identified for screening, nine studies were included. Pooled analysis indicated that NGS had the highest detection rate among the microbial detection methods (NGS vs. sonicated, odds ratios [OR] 5.09, 95% confidential interval [CI] 1.67–15.50; NGS vs. synovial, OR 4.52, 95% CI 2.86–7.16). Sonicated fluid culture showed a higher detection rate than synovial fluid culture (OR 2.11, 95% CI 1.23–3.62). Conclusion: NGS might be useful as a screening tool for culture-negative patients. In clinical settings, sonicated fluid culture is a practical method for diagnosing PJI. [ABSTRACT FROM AUTHOR]

Staphylococcus aureus is the most common microbe in prosthetic joint infections (PJIs). Debridement, antimicrobials, and implant retention (DAIR) are often-recommended treatment modality for acute PJIs, even though it has had relatively poor outcomes in some studies. In this study, we wanted to examine treatment results with a multidisciplinary team in a specialised centre and obtain further information for treatment decisions in acute Staphylococcus aureus PJIs. All consecutive haematogenous late acute and postoperative early acute hip and knee Staphylococcus aureus PJIs treated with DAIR during 2011–2016 were included in this retrospective study. DAIR within three weeks from symptom onset and the exchange of modular parts were required. Eighty-five acute Staphylococcus aureus PJIs were treated with DAIR in 83 patients: 28 late acute and 57 early acute PJIs. The late acute PJI patients were older and had malignancies more often than the early acute PJI patients. Bacteraemia was present in 50.6% of Staphylococcus aureus PJI patients, more often in late acute (73.1%) than in early acute (40.4%) patients (p =.006). The implant was retained in 80.0%: 89.3% of the late acute and 75.4% of the early acute PJIs. In 17 joints, DAIR failed and the joint had to be removed. Fourteen of these joints were successfully replaced. One infection-related death occurred. The one-year all-cause mortality rate was 3.6%. Suppressive antimicrobial treatment was given to 22 (26.5%) patients. Reasonably good treatment results for acute Staphylococcus aureus PJIs are achievable by DAIR in a specialised centre with a strict treatment protocol and a multidisciplinary team. If the DAIR fails, a two-stage exchange is usually still possible, with good results. [ABSTRACT FROM AUTHOR]

Purpose: We aim to compare the outcome of culture-positive (CP PJI) and culture-negative (CN PJI) acute knee prosthetic joint infection (PJI) following debridement, antibiotics and implant retention (DAIR) with polyethylene insert exchange. We also aim to analyze the factors associated with the successful outcome of DAIR and the influence of failed DAIR on the outcome of subsequent two-stage revision arthroplasty. Methods: We performed a retrospective review of 36 consecutive patients who underwent DAIR for acute PJI between January 2013 and January 2018. The patient's demographic data, McPherson grade, surgical details, laboratory and microbiology data were retrieved from the medical records. All the patients have been followed up for a minimum of 3 years or until re-operation, revision or death and any complications, incidence of DAIR failure, revision and mortality were noted. Results: The mean follow-up was 4.9 ± 2.4 years. Among the 36 patients, 16 had CP PJI and 20 had CN PJI. Among the 16 patients with CP PJI, 8 patients had success with DAIR and 8 patients had a recurrence of infection (50%) at a mean of 21 months (range, 2 weeks to 55 months). Among the 20 patients with CN PJI, 14 patients had success with DAIR and 6 patients had a recurrence of infection [30% (6/20)] at a mean of 69 months (range, 13–221 months) (p <.05). The Kaplan–Meir survival analysis showed survivorship did not vary significantly between both groups (p >.05). Univariate regression analysis showed symptom duration of more than one month found to be significantly associated with the DAIR failure. There was no difference in failure rate after DAIR between age, Charlson comorbidity index, early postoperative versus acute hematogenous group and type of organism grown. Ten out of 14 DAIR failures were successfully managed with two-stage revision surgery with no recurrence of infection till the final follow-up. In the remaining 4 patients, one underwent re-debridement, two underwent arthrodesis and one was left with an antibiotic cement spacer. Conclusion: DAIR with polyethylene exchange will give comparable results irrespective of the culture positivity. Symptom duration of more than 30 days for DAIR is significantly associated with DAIR failure. DAIR failures can be successfully managed with two-stage revision. [ABSTRACT FROM AUTHOR]

Background:Staphylococcus lugdunensis is a coagulase-negative staphylococci that is considered normal skin microbiota. It has been described as a cause of soft tissue infections but is not a common micro-organism as the cause of orthopedic surgery-related infections. This study describes the characteristics, treatment, and results of musculoskeletal infection by Staphylococcus lugdunensis treated in our institution. Methods: We performed a descriptive, retrospective observational study. Clinical records of all musculoskeletal infections treated in our department between 2012 and 2020 were reviewed. We selected those patients with a positive monomicrobial culture for Staphylococcus lugdunensis. Risk factors for infection, patient's medical records, previous surgery performed, time from surgery to infection, culture antibiogram, antibiotic and surgical treatment for the infection, and recovery rate were registered for the analysis. Results: Of the 1,482 patients with musculoskeletal infections diagnosed in our institution, 22 had a monomicrobial positive culture of Staphylococcus lugdunensis after an orthopedic surgery representing 1.5% of all orthopedic infections. Ten patients underwent arthroplasty, six underwent fractures synthesis, three had foot surgeries, two had anterior cruciate ligament reconstructions, and one had spine surgery. All patients needed surgery and antibiotic treatment with a mean of two surgeries. The most used antibiotic scheme was levofloxacin-rifampicin. The mean follow-up was 36 months. Ninety-six percent of the patients achieved a complete clinical and analytical recovery. Conclusions: Although musculoskeletal infections caused by Staphylococcus lugdunensis are not common, we have observed a statistically significant incidence increase of Staphylococcus lugdunensis in recent years. If managed with appropriately aggressive surgical treatment and correct antibiotic therapy, good results can be obtained. [ABSTRACT FROM AUTHOR]

We present the first case report of prosthetic joint infection (PJI) caused by Kocuria rhizophila. Our patient is a 74-year-old male who underwent primary total hip replacement for right hip pain. His recovery was uneventful until 6 weeks postoperatively when he presented to his routine outpatient appointment with significant erythema, swelling, and tenderness over his right hip wound. Based on the acuity of his symptoms and the radiological findings, it was determined that the patient should undergo debridement, antibiotics, and implant retention (DAIR procedure). A consensus decision was also made at our PJI multidisciplinary meeting to treat him with 12 weeks of IV antibiotics. After completing this 12 weeks course of IV Vancomycin, his inflammatory markers returned to normal limits. At 6 months follow-up, our patient was mobilizing independently without any signs of infection recurrence. His radiographs showed the implant was in a satisfactory position with no evidence of loosening. This case adds to an emerging body of literature describing invasive infections associated with Kocuria species. We have demonstrated the effectiveness of managing this condition with debridement, implant retention, and IV Vancomycin therapy for 12 weeks. [ABSTRACT FROM AUTHOR]

Although 2-stage revision has been proposed as gold standard for periprosthetic joint infection treatment, limited evidence exists for the role of articulating spacers as definitive management. The purpose of this study was to compare clinical outcomes and costs associated with articulating spacers (1.5-stage) and a matched 2-stage cohort. A retrospective review was performed for patients who had chronic periprosthetic joint infections after total knee arthroplasty defined by Musculoskeletal Infection Society criteria and were matched via propensity score matching using cumulative Musculoskeletal Infection Society scores and a comorbidity index. Patients who maintained an articulating spacer (cemented cobalt-chrome femoral component and all-poly tibia) were included in the 1.5-stage cohort. Patients who underwent a 2-stage reimplantation procedure were included in the 2-stage cohort. Outcomes included visual analog scale pain scores, 90-day emergency department visits, 90-day readmission, unplanned reoperation, reinfection, as well as cost at 1 and 2-year intervals. A total of 116 patients were included for analyses. The 90-day pain scores were lower in the 1.5-stage cohort compared to the 2-stage cohort (2.9 versus 4.6, P =.0001). There were no significant differences between readmission and reoperation rates. Infection clearance was equivalent at 79.3% for both groups. Two-stage exchange demonstrated an increased cost difference of $26,346 compared to 1.5-stage through 2 years (P =.0001). Regression analyses found 2 culture-positive results with the same organism decreased the risk for reinfection [odds ratio: 0.2, 95% confidence interval 0.04-0.8, P =.03]. For high-risk candidates, articulating spacers can preserve knee function, reduce morbidity from second-stage surgery, and lower the costs with similar rates of infection clearance as 2-stage exchange. Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Surgical site infections (SSI) continue to represent a significant postoperative burden. SSI is associated with an increased risk of morbidity and mortality. Systemic antibiotic prophylaxis (SAP) is used to reduce the risk of SSI. Several factors must be considered for appropriate antibiotic use: antibiotic selection, timing, and duration. The evidence and use of antibiotics differs between closed fractures, open fractures, arthroplasty and percutaneous fixation. The use of SAP is a balance between reducing the incidence of SSI whilst maintaining proper antibiotic stewardship to limit adverse effects and the emergence of antibiotic resistance. This paper will discuss the evidence for the use of SAP in orthopaedic surgery and the potential adverse effects of the injudicious use of antibiotics. [ABSTRACT FROM AUTHOR]

Background: Increasing antibiotic resistance has been reported as an issue in the systemic treatment of periprosthetic joint infection (PJI). Linezolid offers the advantages of high oral bioavailability and little resistance; however, efficacy in the treatment of PJI varies considerably, and studies reporting consistent surgical treatment are scarce. Methods: This is a retrospective, single-center analysis of two-stage revisions performed between 2008 and 2017. We identified 111 patients who met the inclusion criteria. Oral linezolid was given for 28 days following 14 days of intravenous tailored antibiotics in resistant gram-positive PJI. A total of 64% of the patients had methicillin-resistant coagulase-negative staphylococci. The median follow-up was 43 (interquartile range (IQR) 30–57) months. Results: 22% (24/111) of the patients underwent surgery for subsequent infection. The 5-year infection-free survival probability was 77% (95% confidence interval (CI) 69–85). A total of 5% of the patients (6/111) had the same organism at the time of reinfection. The patients with infections caused by other organisms than Coagulase-negative staphylococci tended to have a worse reinfection-free survivorship at five years (70% vs. 81%, p = 0.09). Furthermore, the patients with obesity tended to have reduced reinfection-free survivorship at five years (69% vs. 84%, p = 0.08). Overall, 5% (6/111) of the patients had blood count abnormalities with no treatment discontinuations. Conclusion: Two-stage revision arthroplasty with systemic oral linezolid treatment for resistant gram-positive PJI results in an infection control of 77% at the mid-term. [ABSTRACT FROM AUTHOR]

While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.

Abstract Background Periprosthetic joint infection (PJI) is one of the most common causes of early revision for total hip and knee arthroplasty. Mechanical and chemical debridement typically referred to as debridement, antibiotics, and implant retention (DAIR) can be a successful technique to eradicate PJI in acute postoperative or acute hematogenous infections. This review will focus specifically on the indications, techniques, and outcomes of DAIR. Discussion The success of mechanical and chemical debridement, or a DAIR operation, is reliant on a combination of appropriate patient selection and meticulous technique. There are many technical considerations to take into consideration. One of the most important factors in the success of the DAIR procedure is the adequacy of mechanical debridement. Techniques are surgeon-specific and perhaps contribute to the large variability in the literature on the success of DAIR. Factors that have been shown to be associated with success include the exchange of modular components, performing the procedure within seven days or less of symptom onset, and possibly adjunctive rifampin or fluoroquinolone therapy, though this remains controversial. Factors that have been associated with failure include rheumatoid arthritis, age greater than 80 years, male sex, chronic renal failure, liver cirrhosis, and chronic obstructive pulmonary disease. Conclusions DAIR is an effective treatment option for the management of an acute postoperative or hematogenous PJI in the appropriately selected patient with well-fixed implants.

Objective Prosthetic joint infection (PJI) is the main reason of failure of total joint arthroplasty (TJA). This study aimed to investigate the global trends and network visualization in research of PJI. Methods Publications in PJI search during 1980–2022 were extracted from the Science Citation Index‐Expanded of Web of Science Core Collection database (WoSCC). The source data was investigated and analyzed by bibliometric methodology. For network visualization, VOS viewer and R software was used to perform bibliographic coupling, co‐citation, co‐authorship and co‐occurrence analysis and to predict the publication trends in PJI research. Results There were 7288 articles included. The number of publications and relative research interests increased gradually per year globally. The USA made the highest contributions in the world and with the highest H‐index and the most citations. Journal of Arthroplasty published the highest number of articles in this area. The Mayo Clinic, Thomas Jefferson University (Rothman Institute), Hospital Special Surgery and the Rush University were the most contributive institutions by network visualization. Included studies were divided into four clusters: bacterial pathogenic mechanism and antibacterial drugs study, TJA complications, risk factors and epidemiology of PJI, diagnosis of PJI, and revision surgical management. More articles in PJI could be published over the next few years. Conclusion The number of publications about PJI will be increasing dramatically based on the global trends and network visualization. The USA made the highest contributions in PJI. Diagnosis and revision management may be the next hot spots in this field.

Aims: Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. Methods: We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. Results: The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. Conclusion: We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection. Cite this article: Bone Jt Open 2023;4(4):226–233.

Yali Yu,1,&ast; Shaohua Wang,2,&ast; Guixiang Dong,1 Yanli Niu3 1Department of Clinical Laboratory, Zhengzhou Orthopaedics Hospital, Zhengzhou, People’s Republic of China; 2Department of Joint Surgery, Zhengzhou Orthopaedics Hospital, Zhengzhou, People’s Republic of China; 3Laboratory of Cell Signal Transduction, School of Basic Medical Sciences, Henan University, Kaifeng, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Yanli Niu, Laboratory of Cell Signal Transduction, School of Basic Medical Sciences, Henan University, Kaifeng, People’s Republic of China, Email nyl0925@vip.henu.edu.cnPurpose: The purpose of this study was to evaluate the ability of metagenomic next-generation sequencing (mNGS) diagnosing prosthetic joint infection (PJI) using tissue from hip/knee rapidly and precisely, especially in patients who had received antibiotic treatment within the preceding two weeks.Methods: From May 2020 to March 2022, 52 cases with suspected PJI were enrolled. mNGS was performed on surgical tissue samples. The sensitivity and specificity of mNGS in diagnosis was evaluated using culture in conjunction with MSIS criteria. This study also looked at how antibiotic use affected culture and mNGS efficacy.Results: According to MSIS criteria, 31 of the 44 cases had PJI, and 13 were classified in the aseptic loosening group. Sensitivity, specificity, positive/negative predictive value (PPV/NPV), positive/negative likelihood ratio (PLR/NLR), and area under the curve (AUC) of mNGS assay were 80.6% (71.9– 91.8%), 84.6 (73.7– 97.9%), 92.6 (84.2– 98.7%), 64.7 (58.6– 74.7%), 5.241 (4.081– 6.693), 0.229 (0.108– 0.482) and 0.826 (0.786– 0.967), respectively, with MSIS as a reference. When MSIS was used as a reference, the results of culture assay were 45.2% (40.8– 51.5%), 100 (100.0– 100.0%), 100 (100.0– 100.0%), 43.3 (39.1– 49.5%), +∞, 0.548 (0.396– 0.617) and 0.726 (0.621– 0.864), respectively. The AUC values for mNGS and culture were 0.826 and 0.731, respectively, and the differences were insignificant. mNGS demonstrated higher sensitivity than culture in PJI subjects who had previously received antibiotic treatment within 2 weeks (69.5% vs 23.1%, P = 0.03).Conclusion: In our series, mNGS yield a higher sensitivity for diagnosis and pathogen detection of PJI compared to microbiological culture. Additionally, mNGS is less affected by prior antibiotic exposure.Keywords: prosthetic joint infection, metagenomic next⁃generation sequencing MSIS criteria, antibiotic treatment

Immunocompromised patients are at risk of opportunistic infections. This is a 67-year-old woman with systemic sclerosis and knee osteoarthritis who underwent left total knee arthroplasty in 2009. In 2018 she underwent surgery for presumed aseptic loosening. Inflammation and purulent fluid were found; implant was removed and replaced with a static spacer. Three weeks later, H. capsulatum was isolated. She was successfully treated with itraconazole for 18 months; cultures on revision spacer replacement surgery were negative.

Background Coxiella burnetii (C. burnetii) is the causative agent of Q fever and is found worldwide; however, prosthetic joint infections caused by C. burnetii are rarely seen. Because of advances in molecular diagnostic techniques, prosthetic joint infection (PJI) caused by C. burnetii can now be diagnosed. Case Presentation A 77‐year‐old male who had undergone total knee arthroplasty had a displaced prosthesis and periprosthetic osteolysis; he had no obvious signs of infection, and microbiological culture was negative. However, C. burnetii was detected by metagenomic next‐generation sequencing (mNGS) and pathogen‐targeted next‐generation sequencing (ptNGS). Finally, polymerase chain reaction (PCR) confirmed the diagnosis of C. burnetii prosthetic joint infection (PJI). After revision surgery (one‐stage revision) and oral antibiotics (doxycycline and moxifloxacin hydrochloride), the patient's symptoms disappeared, and he regained the ability to walk. During the 6‐month follow‐up, the patient's knee showed no signs of swelling, pain or the recurrence of infection, and he experienced no significant complications. We also present a review of the literature for other cases of C. burnetii PJI. Conclusions The symptoms of C. burnetii PJI may be different from those of Q fever, which may lead to misdiagnosis. mNGS and ptNGS may be helpful for the identification of C. burnetii. Once the diagnosis of C. burnetii PJI is confirmed, doxycycline in combination with a fluoroquinolone can be effectively administered after revision surgery.

Perioperative infection prophylaxis is a fundamental element of total knee arthroplasty (TKA). There has been a recent trend toward the use of extended postoperative oral antibiotics in high-risk patients. We describe a case report of a patient who underwent a primary TKA and subsequently developed Clostridium difficile colitis after an extended course of postoperative prophylactic oral cefadroxil. Following the C. difficile infection, the patient eventually developed bacteremia and a multidrug-resistant Escherichia coli prosthetic joint infection which required multiple debridements. Extended use of postoperative prophylactic oral cefadroxil may increase the risk of C. difficile-associated diarrhea. Additionally, our case suggests that C. difficile infection may subsequently increase the risk of bacteremia which could lead to prosthetic joint infection. More evidence is required to further define this risk.

Background: Prosthetic joint infection (PJI) is a well-described complication after total joint arthroplasty which imposes a substantial burden of morbidity and mortality on the individual, as well as cost to the health-care system. This study used a break-even analysis to investigate the cost-effectiveness of pulsed saline lavage (PSL) for PJI prophylaxis after a primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods: An established model was used to calculate the minimum cost-effective absolute risk reduction of PSL for infection prophylaxis after a total joint arthroplasty. Baseline infection rates of TKA and THA and the cost of a revision surgery for PJI were derived from the literature while the cost of PSL implementation was obtained from institutional data. Results: PSL is cost-effective at an initial infection rate of 1.10%, revision costs of $32,132 for TKA PJI, and a protocol cost of $38.28 if it reduces infection rates by 0.12% or prevents infection in 1 out of 839 patients. PSL is cost-effective at an initial infection rate of 1.63% and a revision cost of $39,713 for THA PJI if it reduces infection rates by 0.10% or prevents infection in 1 out of 1037 patients. The absolute risk reduction needed for economic viability did not change with varying baseline infection rates and did not exceed 0.38% for infection treatment costs as low as $10,000 and remained less than 0.47% even if PSL cost was as high as $150. Conclusions: The use of PSL is a cost-effective protocol for PJI prophylaxis after TKAs and THAs.

Objective C‐reactive protein (CRP), erythrocyte sedimentation rate (ESR), plasma fibrinogen and D‐Dimer are used as diagnostic biomarkers of prosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of the study was to investigate the normal trajectory of CRP, ESR, plasma fibrinogen and D‐Dimer at different time points after two‐stage exchange arthroplasty for PJI. Methods We studied 53 patients undergoing two‐stage exchange for PJI at five time points: preoperatively (T0), duration of hospital stays (T1), 30 days (T2), 30–90 days (T3), and 90–180 days (T4) after surgery. The medical records of all patients were well documented and carefully reviewed. The Shapiro–Wilk test was utilized to compare the normal distribution for continuous variables, and the nonnormally distributed data were used for Friedmann's one‐way repeat measures analysis of variances. Post hoc Dunnett's test was used to compare each pair of data to find differences from baseline. Results Compare with T0 point, the levels of CRP and ESR increased significantly and reached peak values at T1 point (all P 0.05). Conclusions The study demonstrated the normal trajectory of CRP, ESR, plasma fibrinogen and D‐Dimer at five time points in patients who underwent two‐stage exchange for PJI. Thus, the results have the possibility of providing signs of infection after the patient receives two‐stage exchange arthroplasty for PJI, which can benefit from early treatment.

Background: The literature has displayed conflicting evidence on resident involvement in surgical procedures. The goal of this study was to assess the impact of resident involvement on primary total knee arthroplasty (TKA) under a single fellowship-trained adult reconstruction surgeon. Methods: Two hundred sequential patients were retrospectively reviewed by a single surgeon: the first cohort represented the final 100 TKAs performed by the surgeon without resident involvement (NRI), serving as the control group, and the second cohort represented the initial 100 TKAs performed by the same surgeon with resident involvement (RI), serving as the experimental group. Perioperative variables such as number of people in operating room (OR), surgical time, and tourniquet time, and postoperative variables such as infection, minor complications, medial distal femoral angle, medial proximal tibia angle, and total angulation were assessed. Results: The rate of infection was significantly lower in the RI group (0%) compared to the NRI group (1%) (P = .043). The number of staff in the OR (P < .001), the tourniquet time (P < .001), and OR time (P < .001) were significantly higher in the RI group compared to the NRI group. There was no difference in coronal plane radiographic measurements: medial distal femoral angle (P = .10), medial proximal tibia angle (P = .19), or total angulation (P = .27). Conclusions: Resident involvement in primary TKA neither demonstrated any significant difference in coronal plane radiographic alignment of the prosthesis nor an increased risk of infection despite increased operative time, tourniquet time, and number of people in OR. Level of evidence: Level 3 - Therapeutic retrospective cohort study.

Background: Periprosthetic joint infection is a serious complication and devastating mode of failure of total hip arthroplasty. Various surgical approaches exist for total hip arthroplasty, including the increasingly popularised direct anterior approach. There is no clear consensus on which approach is least associated with periprosthetic joint infection. The objective of this meta-analysis was to compare the rate of periprosthetic joint infection between surgical approaches to primary total hip arthroplasty for osteoarthritis. Methods: A search of 3 electronic databases (PubMed/MEDLINE, Embase, and Cochrane Library) was conducted for relevant studies up to June 2020 with a defined list of inclusion and exclusion criteria. Randomised controlled trials and longitudinal studies reporting periprosthetic joint infection rates after primary total hip arthroplasty for osteoarthritis were included based on surgical approach. Data extraction was completed, and a meta-analysis was then performed using OpenMeta[Analyst] software. Results: A total of 24,407 hips were included for meta-analysis with an overall PJI incidence of 0.57%. The incidence rate for periprosthetic joint infection was 0.77% in the direct anterior approach group and 0.44% in the non-anterior approach group. The use of an anterior approach for a total hip arthroplasty was associated with an increased risk for periprosthetic joint infection (odds ratio = 1.404; 95% confidence interval, 0.711–2.771; p = 0.03). Conclusions: The direct anterior approach to total hip arthroplasty may be associated with a significantly increased risk for periprosthetic joint infection compared to non-anterior approaches, even though the overall rate was still small. This should be considered by orthopedic surgeons when choosing the surgical approach. [ABSTRACT FROM AUTHOR]

Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two‐stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft‐tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA. [ABSTRACT FROM AUTHOR]

Manipulation under anesthesia (MUA) is an established option for improving motion in patients presenting with early stiffness following total knee arthroplasty (TKA). Intra-articular corticosteroid injections (IACI) are sometimes administered adjunctively, yet literature examining their efficacy and safety remains limited. Retrospective, Level IV. A total of 209 patients (TKA = 230) were retrospectively examined to determine the incidence of prosthetic joint infections within 3 months following manipulation with IACI. Approximately 4.9% of initial patients had inadequate follow-up where the presence of infection could not be determined. Range of motion was assessed in patients who had follow-up at or beyond one year (n = 158) and was recorded over multiple time points. No infections (0 of 230) were identified within 90 days of receiving IACI during TKA MUA. Before receiving TKA (preindex), patients averaged 111° of total arc of motion and 113° of flexion. Following index procedures, just prior to manipulation (pre-MUA), patients averaged 83° and 86° of total arc and flexion motion, respectively. At final follow-up, patients averaged 110° of total arc of motion and 111° of flexion. At six weeks following manipulation, patients had gained a mean of 25° and 24° of their total arc and flexion motion found at 1 year. This motion was preserved through a 12-month follow-up period. Administering IACI during TKA MUA does not harbor an elevated risk for acute prosthetic joint infections. Additionally, its use is associated with substantial increases in short-term range of motion at six weeks following manipulation, which remain preserved through long-term follow-up. [ABSTRACT FROM AUTHOR]

The incidence of re-revision knee arthroplasty (re-revision KA) is increasing and associated with high complication and failure rates. The aim of this study was to investigate re-revision rates, complications, and patient-reported outcomes following re-revision KA and factors associated with poor outcome. This was a retrospective cohort study of 206 patients (250 knees) undergoing re-revision KA at a major revision center from 2015 to 2018. The mean follow-up was 26 months (range, 0 to 61) and mean age at re-revision KA was 69 years (range, 31 to 91 years). The main indications for surgery were prosthetic joint infection (PJI) (n = 171/250, 68.4%) and aseptic loosening (n = 25/250, 10.0%). We compared re-revision rates, joint function, and complications for aseptic and infective indications. Logistic regressions were performed to identify risk factors for further reoperation. The estimated re-revision rates at 2 years were 28.7% (95% confidence interval [CI]: 22.7-35.9) and at 4 years were 42.0% (95% CI: 32.8-52.6). Mean Oxford Knee Score was 26 points (range, 1 to 48). Mean EuroQoL-5D-5L utility was 0.539 (range, -0.511 to 1.000). Multivariable analyses demonstrated that PJI (Odds Ratio [OR] 2.39, 95% CI 1.06-5.40, P =.036), greater number of previous surgeries (OR 1.18, 95% CI 1.04-1.33, P =.008), and higher Elixhauser score (OR 1.06, 95% CI 1.01-1.13, P =.045) were independently associated to further surgery. Re-revision KA carried a high risk of early failure. Multiple revised joints and patients with more comorbidities had worse function. Patients undergoing re-revision KA for PJI should be counseled to expect higher failure rates and complications than patients who have aseptic indications. [ABSTRACT FROM AUTHOR]

Introduction: High body mass index (BMI) and wound drainage following total joint arthroplasty (TJA) can lead to wound healing complications and periprosthetic joint infection. Silver-embedded occlusive dressings and negative pressure wound therapy (NPWT) have been shown to reduce these complications. The purpose of this prospective trial was to compare the effect of silver-embedded dressings and NPWT on wound complications in patients with BMI ≥ 35 m/kg2 undergoing TJA. Methods: We conducted a randomized control trial of patients who had a BMI > 35 m/kg2 and were undergoing primary TJA between October 2017 and February 2020. Patients who underwent revision surgery, or those with an active infection, previous scar, history of wound healing complications, post-traumatic degenerative joint disease with hardware, or inflammatory arthritis were excluded. Patients were randomized to receive either a silver-embedded occlusive dressing (control) or NPWT. Frequency distributions, means, and standard deviations were used to describe patient demographics, postoperative complications, 90-day readmissions, and reoperations. T-test and chi-squared tests were used to test for significant differences between continuous and categorical variables, respectively. Results: Two hundred-thirty patients with 3-month follow-up were included. One-hundred-fifteen patients received the control and 115 patients received NPWT. There were six patients (5.2%) in the control group with wound complications (drainage: n = 5, non-healing wound: n = 1) and two patients (1.7%) in the NPWT with complications (drainage: n = 2). There were no 90-day readmissions in the control group versus two (1.8%) 90-day readmissions in the NPWT group. Finally, three patients (2.6%) in the control group underwent reoperations (irrigation and debridement [I&D], I&D with modular implant exchange, and implant revision), while none in the NPWT group had undergone reoperation. The two groups showed insignificant differences in wound complications (p = 0.28), 90-day readmissions (p = 0.50), and reoperations (p = 0.25). Conclusion: Patients with BMI ≥ 35 m/kg2 undergoing TJA have no statistical difference in early wound complications, readmissions, or reoperations when treated with either silver-embedded dressings or NPWT. [ABSTRACT FROM AUTHOR]

Background Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin. Methods This single-system retrospective review included patients labeled allergic to penicillin or cephalosporin antibiotics who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin. Results A total of 1128 hip and/or knee arthroplasties from 1047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared with the clindamycin and/or vancomycin group (0.9% vs 3.8%; P <.001) including fewer prosthetic joint infections (0.1% vs 1.9%). The frequency of interoperative HSRs was not different between groups (cefazolin = 0.2% vs clindamycin/vancomycin = 1.3%; P =.06). Conclusions The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR. [ABSTRACT FROM AUTHOR]

Pathogens causing prosthetic joint infection (PJI) are thought to gain access to the knee during surgery or from a remote site in the body. Recent studies have shown that there is a distinct microbiome in various sites of the body. This prospective study, and first of its kind, was set up to investigate the presence of possible microbiome in human knee and compare the profile in different knee conditions. We obtained synovial fluid from 65 knees (55 patients) with various conditions that included normal knee, osteoarthritis (OA), aseptic revision, and those undergoing revision for PJI. The contralateral knee of patients who had a PJI were also aspirated for comparison. A minimum of 3 milliliters of synovial fluid was collected per joint. All samples were aliquoted for culture and next - generation sequencing analysis. The highest number of species was found in native osteoarthritic knees (P ≤.035). Cutibacterium, Staphylococcus , and Paracoccus species were dominant in native nonosteoarthritic knees, and meanwhile a markedly high abundance of Proteobacteria was observed in the osteoarthritic joints. Moreover, the contralateral and aseptic revision knees showed a similar trend in bacterial composition (P =.75). The sequencing analysis of patients who had PJI diagnosis, confirmed the culture results. Distinct knee microbiome profiles can be detected in patients who have OA and other knee conditions. The distinct microbiome in the knee joint and the close host-microbe relationships within the knee joint may play a decisive role in the development of OA and PJI. [ABSTRACT FROM AUTHOR]

Patients undergoing total knee arthroplasty (TKA) are at increased risk of venous thromboembolism (VTE). Aspirin has been shown to be effective at reducing rates of VTE. In select patients, more potent thromboprophylaxis is indicated, which has been associated with increased rates of bleeding and wound complications. This study aimed to evaluate the effect of thromboprophylaxis choice on the rates of early prosthetic joint infection (PJI) following TKA. A review of 11,547 primary TKA patients from 2013 to 2019 at a single academic orthopaedic hospital was conducted. The primary outcome measure was PJI within 90 days of surgery as measured by Musculoskeletal Infection Society criteria. There were 59 (0.5%) patients diagnosed with early PJI. Chi-square and Welch-2 sample t -tests were used to determine statistically significant relationships between thromboprophylaxis and demographic variables. Significance was set at P <.05. Multivariate logistic regression adjusted for age, body mass index, sex, and Charlson comorbidity index was performed to identify and control for independent risk factors for early PJI. There was a statistically significant difference in the rates of early PJI between the aspirin and non-aspirin group (0.3 versus 0.8%, P <.001). Multivariate logistic regressions revealed that patients given aspirin thromboprophylaxis had significantly lower odds of PJI (odds ratios = 0.51, 95% confidence interval = 0.29-0.89, P =.019) compared to non-aspirin patients. The use of aspirin thromboprophylaxis following primary TKA is independently associated with a lower rate of early PJIs. Arthroplasty surgeons should consider aspirin as the gold standard thromboprophylaxis in all patients in which it is deemed medically appropriate and should carefully weigh the morbidity of PJI in patients when non-aspirin thromboprophylaxis is considered. Retrospective, Therapeutic Level III. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infection (PJI) is a devastating complication of knee and hip arthroplasty. Past literature has shown that gram-positive bacteria are commonly responsible for these infections, although limited research exists studying the changes in the microbial profile of PJIs over time. This study sought to analyze the incidence and trends of pathogens responsible for PJI over three decades. This is a multi-institutional retrospective review of patients who had a knee or hip PJI from 1990 to 2020. Patients with a known causative organism were included and those with insufficient culture sensitivity data were excluded. There were 731 eligible joint infections from 715 patients identified. Organisms were divided into multiple categories based on genus/species and 5-year increments were used to analyze the study period. The Cochran-Armitage trend tests were used to evaluate linear trends in microbial profile over time and a P -value <.05 was considered statistically significant. There was a statistically significant positive linear trend in the incidence of methicillin-resistant Staphylococcus aureus over time (P =.0088) as well as a statistically significant negative linear trend in the incidence of coagulase-negative staphylococci over time (P =.0018). There was no statistical significance between organism and affected joint (knee/hip). The incidence of methicillin-resistant Staphylococcus aureus PJI is increasing over time, whereas, coagulase-negative staphylococci PJI is decreasing, paralleling the global trend of antibiotic resistance. Identifying these trends may help with the prevention and treatment of PJI through methods such as remodeling perioperative protocols, modifying prophylactic/empiric antimicrobial approaches, or transitioning to alternative therapeutic strategies. [ABSTRACT FROM AUTHOR]

The concordance between preoperative synovial fluid cultures and intraoperative tissue cultures for identifying pathogenic microorganisms in shoulder periprosthetic joint infection (PJI) remains poorly understood. The purpose of our study was to examine the diagnostic accuracy of positive synovial fluid culture results in early pathogen identification for shoulder PJI. A total of 35 patients who met the Musculoskeletal Infection Society criteria for PJI following primary anatomic or reverse arthroplasty and the study inclusion criteria were identified retrospectively from a single institution (multiple surgeons) from January 2011 to June 2021. The inclusion criteria required a positive preoperative intra-articular synovial fluid sample within 90 days analyzed within the same institution and intraoperative tissue cultures at the time of arthrotomy. Concordance was determined when the organism(s) identified from the aspirate correlated with the intraoperative specimens. Overall concordance was identified in 28 of 35 patients (80%), with similar concordance for anatomic (21 of 24, 88%) and reverse (7 of 11, 64%) shoulder arthroplasties (P =.171). Culture discordance occurred in 7 of 35 patients (20%): of these, 5 (14%) had no corresponding intraoperative culture growth whereas 2 (6%) had polymicrobial intraoperative cultures. Monomicrobial Cutibacterium acnes PJI cases were the most common (24 of 35, 69%) and had an overall concordance rate of 79%. Of 5 discordant C acnes patients, 2 had polymicrobial intraoperative cultures and 3 had negative intraoperative culture results; all the patients with negative intraoperative culture results had received antibiotics between the time of aspiration and surgery. Considered separately, concordance in patients who had a positive aspirate finding for C acnes and did not receive antibiotics prior to surgery was 19 of 21 (90%), with a sensitivity of 100% (95% confidence interval, 82%-100%) and a corresponding positive predictive value of 0.91 (95% confidence interval, 58%-93%). Preoperative positive aspiration culture results demonstrated favorable sensitivity and specificity when compared with intraoperative tissue cultures in identifying pathogenic microorganisms in shoulder PJI patients. These findings are congruent with literature from hip and knee arthroplasty. Ultimately, confidence in the accuracy of positive preoperative aspiration culture results in shoulder PJI may facilitate the development of early, targeted treatment strategies while directing patient expectations and risk. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate whether the presence of Staphylococcus aureus (SA) producing the Panton–Valentine leukocidin (PVL) affects the outcome of Prosthetic Joint Infection (PJI). Patients with acute and chronic PJI sustained by SA were prospectively enrolled at the orthopedic unit of "Casa di Cura Santa Maria Maddalena", from January 2019 to October 2021. PJI diagnosis was reached according to the diagnostic criteria of the International Consensus Meeting on PJI of Philadelphia. Synovial fluid obtained via joint aspirations was collected in order to isolate SA. The detection of PVL was performed via real-time quantitative PCR (RT-qPCR). The outcome assessment was performed using the criteria of the Delphi-based International Multidisciplinary Consensus. Twelve cases of PJI caused by SA were included. Nine (75%) cases were acute PJI treated using debridement, antibiotic and implant retention (DAIR); the remaining three (25%) were chronic PJI treated using two-stage (n = 2) and one-stage revision (n = 1), respectively. The SA strains that tested positive for PVL genes were 5/12 (41.6%,). Treatment failure was documented in three cases of acute PJI treated using DAIR, all supported by SA–PVL strains (p < 0.045). The remaining two cases were chronic PJI treated with a revision arthroplasty (one and two stage, respectively), with a 100% eradication rate in a medium follow-up of 24 months. Although a small case series, our study showed a 100% failure rate in acute PJI, probably caused by SA PVL-producing strains treated conservatively (p < 0.04). In this setting, toxin research should guide radical surgical treatment and targeted antibiotic therapy. [ABSTRACT FROM AUTHOR]