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Resumen La artroplastia total de rodilla es una de las cirugias realizadas con mas frecuencia en ortopedia. No obstante, hasta un 20% de los pacientes mostraran persistencia del dolor despues del procedimiento. El dolor posquirurgico persistente puede ser una continuacion del dolor agudo tras la cirugia o aparecer despues de un periodo asintomatico durante mas de 3 meses. En la actualidad, se han caracterizado los factores de riesgo que se asocian a dolor posquirurgico persistente tras la artroplastia total de rodilla. Forman parte del contexto perioperatorio del paciente (preoperatorio, intraoperatorio y postoperatorio) y se pueden agrupar en diferentes dimensiones: geneticas, demograficas, clinicas, quirurgicas, analgesicas, inflamatorias y psicologicas. Su identificacion y prevencion, mediante un abordaje multimodal y biopsicosocial, es esencial en el contexto de la medicina perioperatoria y ha demostrado que puede prevenir o mejorar el dolor tras la cirugia.

It remains unclear whether rheumatoid arthritis might be a cause of false positive of the histology for the diagnosis of prosthetic joint infection. Our aim was to evaluate the usefulness of the histology for the diagnosis of infection during hip and knee prosthesis revision in patients with rheumatoid arthritis. All patients with the diagnosis of rheumatoid arthritis (RA) undergoing hip or knee revision surgery (total or partial) were retrospectively reviewed. Positive histology was considered when ≥ 5 neutrophils per high-power field (400×) were found in at least five separate microscopic fields. Patients who presented ≥ 2 positive cultures for the same microorganism or the presence of fistula were considered as “true positives”. Thirty-two hip (n = 12) and knee (n = 20) revision procedures were performed. Sensitivity, specificity, positive and negative predictive value of the histology were 50%, 78.6%, 25% and 91.7%, respectively. Six out of the eight patients presenting with positive histology had negative cultures (75.0% of false positives). Our results suggest that, in the context of RA, negative histological results have a very high negative predictive value. RA poses false positive histology results for the diagnosis of infection during hip and knee revision when conventional cultures are used for diagnosis of infection.

Resumen: Antecedentes y objetivo: El 40-50% de estas artritis sépticas se producen en la rodilla, y a pesar del rápido tratamiento médico-quirúrgico, del 24 al 50% van a acabar en un pobre resultado clínico. No está claro qué técnica de desbridamiento por artrotomía o por artroscopia es más eficaz para el control de la infección, ni si la artrosis previa empeora o no el resultado. El objetivo de este estudio en artritis séptica de rodilla artrósica es analizar qué técnica de desbridamiento quirúrgico, artroscopia o artrotomía, es más eficaz, cuál es la evolución clínica y radiográfica de los pacientes y cuántos van a necesitar la implantación de una PTR tras la curación de la infección. Material y método: Se realizó un estudio retrospectivo en 27 pacientes con artritis séptica nativa de rodilla. Dieciocho eran hombres y la edad media fue de 64,8 años (30-89 años). Quince pacientes fueron desbridados por artrotomía y 12 por artroscopia. Se analizó la eficacia del desbridamiento para el control de la infección, la progresión radiográfica de la artrosis en la escala de Ahlbäch, la necesidad de protetización posterior y el dolor y el estado funcional mediante la escala EVA y WOMAC a los 52,8 ± 11,2 meses de evolución. Resultados: El 93 y el 92% de los pacientes controlaron la infección, el 13 y el 42% requirieron dos o más cirugías para el control de la infección, y el 18 y el 44,4% mostraron progresión de la artrosis en el grupo artrotomía y artroscopia, respectivamente. Un paciente de cada grupo requirió que se le implantara una prótesis de rodilla. La escala EVA fue superior en el grupo artrotomía y no hubo diferencias en la escala de WOMAC. Conclusión: El desbridamiento por artrotomía en el área de urgencias por cirujanos no subespecializados en rodilla es más eficaz que el artroscópico para controlar la artritis séptica de rodilla. El desbridamiento quirúrgico de las artritis sépticas en rodillas con artrosis previa permite controlar la infección con ausencia de dolor a pesar de la progresión de la artrosis. Abstract: Background and objective: 40%-50% of this septic arthritis occurs in the knee, despite rapid medical surgical treatment, 24%-50% will have a poor clinical outcome. It is not clear which debridement technique, by arthrotomy or arthroscopy, is more effective in controlling infection, or whether or not previous osteoarthritis worsens the outcome. The objective of this study on septic arthritis of the osteoarthritic knee was to analyse which surgical debridement technique, arthroscopy or arthrotomy, is more effective, the clinical and radiographic outcomes of the patients, and how many go on to require a TKR after the infection has healed. Material and methods: A retrospective study was performed in 27 patients with native septic arthritis of the knee. Eighteen were men and the mean age was 64.8 years (30-89 years). Fifteen patients were debrided by arthrotomy and 12 by arthroscopy. The effectiveness of debridement in controlling infection, the radiographic progression of the osteoarthritis on the Ahlbäch scale, the need for subsequent replacement, and pain and functional status were analysed using the VAS and WOMAC scales at 52.8 ± 11.2-month follow-up. Results: The infection was controlled in 93% and 92% of the patients, 13% and 42% required 2 or more surgeries for infection control, 18% and 44.4% showed progression of arthritis in the arthrotomy and arthroscopy groups, respectively. One patient in each group required a knee replacement. The VAS score was superior in the arthrotomy group and there were no differences in WOMAC score. Conclusion: Debridement by arthrotomy in the emergency department by non-sub-specialist knee surgeons is more effective than arthroscopic debridement in controlling septic arthritis of the knee. Surgical debridement of septic arthritis in knees with previous osteoarthritis enabled control of the infection with no pain despite the progression of the osteoarthritis.

Background and objective 40%–50% of this septic arthritis occurs in the knee, despite rapid medical surgical treatment, 24%–50% will have a poor clinical outcome. It is not clear which debridement technique, by arthrotomy or arthroscopy, is more effective in controlling infection, or whether or not previous osteoarthritis worsens the outcome. The objective of this study on septic arthritis of the osteoarthritic knee was to analyse which surgical debridement technique, arthroscopy or arthrotomy, is more effective, the clinical and radiographic outcomes of the patients, and how many go on to require a TKR after the infection has healed. Methods A retrospective study was performed in 27 patients with native septic arthritis of the knee. Eighteen were men and the mean age was 64.8 years (30–89 years). Fifteen patients were debrided by arthrotomy and 12 by arthroscopy. The effectiveness of debridement in controlling infection, the radiographic progression of the osteoarthritis on the Ahlbach scale, the need for subsequent replacement, and pain and functional status were analysed using the VAS and WOMAC scales at 52.8 ± 11.2-month follow-up. Results The infection was controlled in 93% and 92% of the patients, 13% and 42% required 2 or more surgeries for infection control, 18% and 44.4% showed progression of arthritis in the arthrotomy and arthroscopy groups, respectively. One patient in each group required a knee replacement. The VAS score was superior in the arthrotomy group and there were no differences in WOMAC score. Conclusion Debridement by arthrotomy in the emergency department by non-sub-specialist knee surgeons is more effective than arthroscopic debridement in controlling septic arthritis of the knee. Surgical debridement of septic arthritis in knees with previous osteoarthritis enabled control of the infection with no pain despite the progression of the osteoarthritis.

Resumen En las infecciones protesicas es muy importante realizar un tratamiento correcto con el que podamos asegurar una mayor tasa de exito. Si bien es cierto que el desbridamiento con retencion de implante (DAIR) es una cirugia muy utilizada en infecciones agudas y agudas tardias, se sabe que los pacientes que no logran el exito en este tipo de cirugias presentan mayor riesgo de fracaso en cirugias posteriores. Es por ello que es importante encontrar una escala que nos permita predecir el riesgo de fracaso de DAIR. Asi nacieron la escala KLIC y CRIME80 para infecciones agudas e infecciones agudas tardias, respectivamente. Con este estudio hemos analizado la validez de ambas escalas en infecciones periprotesicas de rodilla agudas tardias y se ha observado que el KLIC no tiene valor predictivo para este tipo de infecciones, pero si la escala CRIME80.

It is very important to treat prosthetic infections correctly in order to ensure a higher success rate. Debridement with implant retention (DAIR) is widely used in acute and late infections, however patients who fail after this surgery are known to have a higher risk of failure in subsequent surgeries. Therefore, it is important to find a scale that enables us to predict the risk of DAIR failure. Hence the KLIC and CRIME80 scores for acute and late acute infections, respectively. This study analysed the validity of both scores in acute late periprosthetic knee infections. We observed that the KLIC score has no predictive value for this type of infection, but the CRIME80 score does.

Background Our aim was to investigate the impact of unexpected positive cultures on the outcome of partial prosthetic revisions. Methods Data regarding patients who underwent a partial hip or knee revision from 2003 and 2012 with the preoperative diagnosis of aseptic loosening was retrospectively reviewed. The protocol of revision included at least 3 intra-operative cultures. Failure was defined as the need for re-revision due to aseptic or septic loosening at 5 years. Results A total of 99 hip and 46 knee partial revisions were included. All cases had at least 5 years follow-up. Ninety-seven cases (66.9%) had all cultures negative, 35 (24.1%) a single positive culture and 13 (9.0%) ≥2 positive cultures for the same microorganism. The median time from primary arthroplasty to partial revision was significantly shorter for patients with ≥2 positive cultures (26 months) than in those with all cultures negative (48 months) or with a single positive culture (51 months). Partial revisions performed within the first 5 years of implantation had a higher 5-year re-revision rate. The presence of a single positive culture during the partial exchange was not associated with a higher re-revision rate (2 out of 35, 5.7%) than in those with negative cultures (3 out of 97, 3.1%). On the contrary, re-revision rate was significantly higher in cases with ≥2 positive cultures (3 out of 13, 23.1%) than in those with negative cultures (p=0.02). Conclusion Partial revisions performed within the first 5 years from implantation and ≥2 intraoperative positive cultures were associated with a higher re-revision risk at 5 years.

Background The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty. Methods We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up Results We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: the failure rate for Week 1–2 was 42% (95/226), the rate for Week 3–4 was 38% (143/378), the rate for Week 5–6 was 29% (29/100), and the rate for Week 7–12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals. Conclusions DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged.

Background: A significant amount of patients undergoing revision surgery of a prosthetic joint turn out to have an infection. Withholding preoperative antibiotic prophylaxis in these patients to optimize culture yield during revision surgery remains a matter of debate. The aim of our study was to determine (1) the rate of positive intraoperative cultures with or without preoperative antibiotic prophylaxis and (2) the incidence of a prosthetic joint infection (PJI) during the follow-up in the 2 groups.Methods: Medical files of patients in whom preoperative antibiotic prophylaxis was withheld until culture samples were taken (2007-2010, n = 284) and in whom antibiotic prophylaxis was given during the induction of anesthesia (2010-2013, n = 141) were retrospectively reviewed.Results: The percentage of >= 1 positive cultures was the same in the group without (26%) and with preoperative prophylaxis (27%; P value, .7). PJI was diagnosed during revision surgery according to the Musculoskeletal Infection Society criteria in 6.7% patients not receiving preoperative prophylaxis and in 7.0% receiving it (P value, .79). We found no important differences in the type of microorganisms that were isolated in both groups. During a 3-month follow-up, an early PJI developed in patients undergoing total revision surgery in 6.4% of the nonpreoperative prophylaxis group vs 1.6% in the preoperative prophylaxis group (P value, .1).Conclusion: Preoperative antibiotic prophylaxis does not reduce culture yield in patients undergoing knee revision surgery. Our data show a trend toward a higher PJI rate in the postoperative period of total revision surgery when preoperative prophylaxis is withheld.

Objectives Early prosthetic joint infections (PJIs) are managed with debridement, implant retention and antibiotics (DAIR). Our aim was to evaluate risk factors for failure after stopping antibiotic treatment. Methods From 1999 to 2013, early PJIs managed with DAIR were prospectively collected and retrospectively reviewed. The main variables potentially associated with outcome were gathered, and the minimum follow-up was 2 years. For the present study, only patients who were in remission after one debridement and without long-term antibiotic suppression were included. The primary endpoint was implant removal or the need to reintroduce antibiotic treatment due to failure. Results One-hundred-and-forty-three patients met the inclusion criteria. The failure rate after a median duration of oral antibiotic treatment of 69 days (IQR 45-95 days) was 11.8%. In 92 cases, PJI was due to Gram-positive microorganisms, in 21 cases PJI was due to Gram-negative microorganisms and in 30 cases PJI was due to a polymicrobial infection with both Gram-positive and Gram-negative microorganisms. In Gram-positive infections, rifampicin administered in combination with linezolid, co-trimoxazole or clindamycin was associated with a higher failure rate (27.8%, P = 0.026) than that in patients receiving a combination of rifampicin with levofloxacin, ciprofloxacin or amoxicillin (8.3%) or monotherapy with linezolid or co-trimoxazole (0%). Among patients with a Gram-negative infection, the use of fluoroquinolones was associated with a lower failure rate (7.1% versus 37.5%, P = 0.044). Conclusions The only factor associated with failure was the oral antibiotic selection, not the duration of treatment. Linezolid, co-trimoxazole and clindamycin, but not levofloxacin, serum concentrations are reduced by rifampicin; a fact that could explain our findings. Further studies monitoring serum concentration could help to improve the efficacy of these antibiotics when administered in combination with rifampicin.

Stiffness after a total knee arthroplasty (TKA) is one of the most common post-operative complications. The purpose of this study is the evaluation of the effectiveness of TT proximalization osteotomy of improving a lack of flexion and secondary pain in patella baja (infera) post-TKA.Between April 2007 and July 2012, TT proximalization osteotomy was performed on 21 patients. The average preoperative flexion was 70° (in a range of 60-80). Clinical pre- and post-operative evaluations were performed with Knee Society Score, Western Ontario and McMaster Universities Arthritis Index scales and a satisfaction survey. Modified Blackburn-Peel index and Portner angle were used to evaluate patellar height.After an average follow-up of 35 months (range 18-48), an average flexion of 100° (range 90-100) and an overall satisfaction were obtained. Clinical scores improved significantly. The Blackburn-Peel index and Portner angle improved significantly from 0.3 (range 0.1-0.5) to 0.4 (0.3-0.5) and from 9 (3-15) to 12 (9-18), respectively. Three patients showed no signs of osteotomy consolidation. However, this was not linked to a lack of extension or an increase in local pain.TT proximalization osteotomy provides satisfactory results in improving a lack of flexion and pain in patella baja post-TKR.

The aim of this study was to compare the prosthetic joint infection (PJI) rate after total joint arthroplasty in two consecutive periods of treatment with different antibiotic prophylaxes: cefuroxime versus cefuroxime plus teicoplanin. We retrospectively reviewed 1,896 patients who underwent total hip arthroplasty or total knee arthroplasty between March 2010 and February 2013. From March 2010 to August 2011, patients received 1.5 g of cefuroxime during induction of anesthesia and another 1.5 g 2 h later (the C group). From September 2011, 800 mg of teicoplanin was added to cefuroxime (the CT group). Throughout the period studied, there were no variations in pre- or postoperative protocols. Univariate and multivariate analyses were performed to evaluate independent predictors of PJI. There were 995 (55.7%) patients in the C group and 791 (44.3%) in the CT group. Patients in the CT group had a significantly lower PJI rate than patients in the C group (1.26% versus 3.51%, P = 0.002). There were no infections due to Staphylococcus aureus in the CT group (0% versus 1.6% in the C group, P < 0.001). A stepwise forward Cox regression model identified male sex (hazard ratio [HR], 3.85; 95% confidence interval [CI], 2.09 to 7.18), a body mass index of ≥35 kg/m 2 (HR, 2.93; 95% CI, 1.37 to 6.27), the presence of lung disease (HR, 2.46; 95% CI, 1.17 to 5.15), and red blood cell transfusion (HR, 3.70; 95% CI, 1.89 to 7.23) to be independent variables associated with a higher risk of PJI. The addition of teicoplanin was associated with a lower risk of infection (HR, 0.35; 95% CI, 0.17 to 0.74). In conclusion, the addition of teicoplanin to cefuroxime during primary arthroplasty was associated with a significant reduction in the global PJI rate due to a reduction of infections caused by Gram-positive bacteria.

The aim of our study was to determine the potential influence of blood transfusion and the length of storage of packed red blood cells (RBC) on prosthetic joint infection after primary knee arthroplasty. From November 2007 to November 2009, all variables potentially associated with deep infection were registered in 1331 consecutive patients who underwent total knee arthroplasty. Infection was diagnosed in 32 (2.4%) patients. After adjusting for important variables, blood transfusion with RBCs stored >14days was the strongest predictive factor for prosthetic joint infection within 90days after primary knee arthroplasty (OR: 5.9, 95% CI: 2.6-13.2, P < 0.001). Blood saving techniques are desirable to reduce perioperative blood transfusion.

Purposes The aim of the present study was to evaluate the importance of isolated microorganisms according to the Gram stain and the type of antibiotic received on the outcome of early prosthetic joint infection (PJI) treated with debridement, antibiotics and implant retention (DAIR). Methods From January 1999 to December 2009, all patients with an early PJI were prospectively registered in a database and they were retrospectively reviewed for this study. Results During the study period, 160 patients met the inclusion criteria of the study. After a mean (SD) post-debridement follow-up of 5.2 (2.5) years, 117 patients (73.1%) were considered to be in remission and 43 (26.9%) were classified as failure. Variables associated with failure were liver cirrhosis (66.7% vs. 22.8%, p=0.001), diagnosis within the first 30 days from arthroplasty (30.4% vs. 8.0%, p=0.020), C-reactive protein (CRP) >12 mg/dl (46.7% vs. 21.2%, p=0.005), microorganism isolated in all deep samples (31.1% vs. 16.0%, p=0.047) and Gram-negative (GN) infection not treated with a fluoroquinolone (57.1% vs. 20.0%, P=0.004). Gram-positive (GP) infection not treated with rifampin was close to be statistically significantly associated with failure (34.4% vs. 19.2%, p=0.067). A multivariate analysis identified liver cirrhosis (OR: 12.4 CI95%: 3.1-49.7, pConclusion The remission rate of PJI treated with DAIR after 3 years of follow-up was 73%. The main predictors of failure were liver cirrhosis, the selected antibiotic most specially fluoroquinolones for GN and rifampin for GP infections, the C-reactive protein and the number of samples culture positive as a potential surrogate markers of bacterial density.

Gram-positive cocci are commonly isolated in orthopaedic implant infections and their resistance to β-lactams and fluoroquinolones is increasing. The high oral bioavailability of linezolid makes it an attractive oral alternative to glycopeptides and its use has increased in the last decade. To evaluate experience with linezolid in orthopaedic implant infections a systematic review of the literature available in English was undertaken. Only those articles describing series of ≥10 patients with acute or chronic orthopaedic implant infections treated with linezolid and with a clear definition of diagnosis and outcome were selected. A total of 293 patients (79.9% had prosthetic joint infections) were analysed in the 10 articles included. The overall remission rate with at least 3 months of follow-up was 79.9%, depending on whether the implant was removed or not (94% versus 69.9%). The addition of rifampicin was described in only two articles and no significant difference was observed. Adverse events were frequent during prolonged administration of linezolid (34.3%), requiring treatment discontinuation in 12.8%. The most common event was anaemia (13.4%) followed by gastrointestinal symptoms (11.1%). In conclusion, linezolid seems a good oral treatment alternative for orthopaedic implant infections due to Gram-positive cocci resistant to β-lactams and fluoroquinolones. However, close monitoring of adverse events is required.

The incidence of revision knee arthroplasty for infection is increasing and the required surgical approach for the revision is a challenge for surgeons. Extensile approaches are frequently used when it is impossible to evert the extensor mechanism. The aim of this paper is to report our experience with tibial tubercle osteotomy (TTO) and the functional results in patients who underwent a two-stage revision due to prosthesis infection. Twenty-six patients underwent a TTO as a surgical approach in the second stage of revision for infection. The patients were clinically assessed by means of functional scales (the Knee Society Score and WOMAC) and X-rays. The TTO healed without complications in 22 patients (84.6 %) and the average length of follow-up was 3.4 years. Non-union was observed in two patients. One patient presented an extension lag of 5°. A total of 23 patients (88.4 %) were free from infection. Twenty-five patients (96.1 %) had better scores on the Knee Society Score and WOMAC after the procedure. In patients undergoing the second stage of revision total knee arthroplasty for infection, the TTO approach provides a large operating field. This enables surgeons to withdraw spacers and position new implants without damaging the extensor mechanism of the knee or altering the postoperative rehabilitation process. The complications that have been reported as a result of this procedure could be reduced by performing a meticulous surgical technique. Retrospective case series, Level IV.

Infection is one of the most serious complications after total knee arthroplasty (TKA). The current incidence of prosthetic knee infection is 1-3%, depending on the series.For treatment and control to be more cost effective, multidisciplinary groups made up of professionals from different specialities who can work together to eradicate these kinds of infections need to be assembled. About the microbiology,Staphylococcus aureusand coagulase-negative staphylococcus were among the most frequent microorganisms involved (74%).Anamnesis and clinical examination are of primary importance in order to determine whether the problem may point to a possible acute septic complication. The first diagnosis may then be supported by increased CRP and ESR levels. The surgical treatment for a chronic prosthetic knee infection has been perfectly defined and standardized, and consists in a two-stage implant revision process. In contrast, the treatment for acute prosthetic knee infection is currently under debate. Considering the different surgical techniques that already exist, surgical debridement with conservation of the prosthesis and polythene revision appears to be an attractive option for both surgeon and patient, as it is less aggressive than the two-stage revision process and has lower initial costs.The different results obtained from this technique, along with prognosis factors and conclusions to keep in mind when it is indicated for an acute prosthetic infection, whether post-operative or haematogenous, will be analysed by the authors.

Levofloxacin plus rifampicin (L+R) is the treatment of choice for acute staphylococcal prosthetic joint infection (PJI) managed with debridement and implant retention (DAIR). Long courses have been empirically recommended, but some studies have suggested that shorter treatments could be as effective. Our aim was to prove that a short treatment schedule was non-inferior to the standard long schedule. An open-label, multicentre, randomised clinical trial (RCT) was performed. Patients with an early post-surgical or haematogenous staphylococcal PJI, managed with DAIR and initiated on L+R were randomised to receive 8 weeks of treatment (short schedule) versus a long schedule (3 months or 6 months for hip or knee prostheses, respectively). The primary endpoint was cure rate. From 175 eligible patients, 63 were included (52% women; median age, 72 years): 33 patients (52%) received the long schedule and 30 (48%) received the short schedule. There were no differences between the two groups except for a higher rate of polymicrobial infection in the long-schedule group (27% vs. 7%; P = 0.031). Median follow-up was 540 days. In the intention-to-treat analysis, cure rates were 58% and 73% in patients receiving the long and short schedules, respectively (difference −15.7%, 95% CI −39.2% to 7.8%). Forty-four patients (70%) were evaluable per-protocol: cure rates were 95.0% and 91.7% for the long and short schedules, respectively (difference 3.3%, 95% CI −11.7% to 18.3%). This is the first RCT suggesting that 8 weeks of L+R could be non-inferior to longer standard treatments for acute staphylococcal PJI managed with DAIR.

Background. Several series predicting the prognosis of staphylococcal prosthetic joint infection (PJI) managed with debridement, antibiotics, and implant retention (DAIR) have been published, but some of their conclusions are controversial. At present, little is known regarding the efficacy of the different antibiotics that are used or their ability to eliminate methicillin-resistant S. aureus (MRSA) infection. Methods. This was a retrospective, multicenter, observational study of cases of PJI by S. aureus that were managed with DAIR (2003–2010). Cases were classified as failures when infection persistence/relapse, death, need for salvage therapy, or prosthesis removal occurred. The parameters that predicted failure were analyzed with logistic and Cox regression. Results. Out of 345 episodes (41% men, 73 years), 81 episodes were caused by MRSA. Fifty-two were hematogenous, with poorer prognoses, and 88% were caused by methicillin-susceptible S. aureus (MSSA). Antibiotics were used for a median of 93 days, with similar use of rifampin-based combinations in MSSA- and MRSA-PJI. Failure occurred in 45% of episodes, often early after debridement. The median survival time was 1257 days. There were no overall prognostic differences between MSSA- and MRSA-PJI, but there was a higher incidence of MRSA-PJI treatment failure during the period of treatment (HR 2.34), while there was a higher incidence of MSSA-PJI treatment failure after therapy. Rifampin-based combinations exhibited an independent protective effect. Other independent predictors of outcome were polymicrobial, inflammatory, and bacteremic infections requiring more than 1 debridement, immunosuppressive therapy, and the exchange of removable components of the prosthesis. Conclusions. This is the largest series of PJI by S. aureus managed with DAIR reported to date. The success rate was 55%. The use of rifampin may have contributed to homogenizing MSSA and MRSA prognoses, although the specific rifampin combinations may have had different efficacies.

PurposesTo review patients with a hematogenous and early post-surgical prosthetic joint infection (PJI) due to S. aureus treated with debridement and retention of the implant and to compare their clinical characteristics and outcome.MethodsFrom January 2000 all patients with a prosthetic joint infection treated in a single-center were prospectively registered and followed-up. All potentially variables associated with outcome were recorded. For the present study, cases with a hematogenous or early post-surgical PJI due to S. aureus treated with debridement and at least 2 years of follow-up were reviewed. Cox regression model to identify factors associated with outcome were applied.Results12 hematogenous and 53 early post-surgical PJI due to S. aureus were included. Number of patients presenting with fever, leucocyte count, C-reactive protein concentration, and the number of bacteremic patients were significantly higher in hematogenous infections while the number of polymicrobial infections was lower in hematogenous than in early post-surgical infections. The global failure rate in hematogenous and early post-surgical PJI was 58.7% and 24.5%, respectively (p=0.02). The Cox regression model identified hematogenous infections (OR: 2.57, CI95%: 1.02–6.51, p=0.04) and the need of a second debridement (OR: 4.61, CI95%: 1.86–11.4, p=0.001) as independent predictors of failure.ConclusionHematogenous infections were monomicrobial and had more severe symptoms and signs of infection than early post-surgical PJI. Hematogenous PJI due to S. aureus, using debridement with implant retention, had a worse outcome than early post-surgical infections.

The pathogenesis of prosthesis loosening is not well understood. The aim of our study was to sonicate components of joint prostheses removed due to aseptic loosening, culture the sonicate fluid, and to correlate these results with the degree of radiological osteolysis.From January 2008 to June 2009 all consecutive patients who underwent a revision of hip or knee prosthesis due to aseptic loosening were included in the study. Aseptic loosening was established when the patient had radiological signs of loosening without symptoms or signs of infection. The diagnosis was confirmed when histology was negative, and ≥ 5 out of 6 standard cultures of periprosthetic tissue were negative. Bone lysis was measured according to the Paprosky or Engh classifications without knowing the result of sonication cultures. Removed components were placed in sterile bags and immediately transported to the microbiology laboratory and sonicated. Sonicate fluid was cultured and the results were correlated with the degree of bone lysis. The proportion of components with positive sonication culture according to the bone lysis classification was compared using χ(2) test.A total of 52 patients were included and 123 components were sonicated. In 30 patients at least 1 sonicated component was positive (57.7%) and 44 out of 123 (35.8%) components were positive. The proportion of positive sonication cultures was significantly higher in the group of components with a higher degree of bone lysis of 3 (76.5%) than in those with lower degrees (33.9% for 1 and 24% for 2) (χ(2) test, p = 0.0004).Sonication cultures were positive in 57% of patients who underwent revision arthroplasty for aseptic loosening. The percentage of positive sonication cultures was significantly higher in patients with severe osteolysis.level I of Prognostic Studies-Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

The aim of our study was to compare the effectiveness of high-pressure pulsatile lavage and low-pressure lavage in patients with an orthopaedic implant infection treated with open débridement followed by antibiotic treatment.Patients with an orthopaedic implant infection requiring open débridement from January 2008 to August 2009 were randomized prospectively to a low-pressure or a high-pressure pulsatile lavage arm. Relevant information about demographics, co-morbidity, type of implant, microbiology data, surgical treatment, and outcome were recorded. Comparison of proportions was made using χ(2) test or Fisher exact test when necessary. The Kaplan-Meier survival method was used to estimate the cumulative probability of treatment failure from open débridement to the last visit.Seventy-nine patients were included. There were no differences between the main characteristics between both groups (p0.05). Mean (SD) age of the whole cohort was 70.2 (11.9) years. There were 46 infections on knee prosthesis, 17 on hip prosthesis, 7 on hip hemiarthroplasties and 9 on osteosynthesis devices. There were 69 acute post-surgical infections, 8 acute haematogenous infections and 2 chronic infections. The most common microorganisms isolated were coagulase-negative Staphylococci in 34 cases, Staphylococcus aureus in 26 and Escherichia coli in 19 cases. There were 30 polymicrobial infections. A total of 42 and 37 patients were randomized to a high-pressure pulsatile or a low-pressure lavage, respectively. There was no difference in the success rate between both arms (80.9 vs. 86.5%, p = 0.56).The use of a high-pressure pulsatile lavage during open débridement of implant infections had a similar success rate as a low-pressure lavage.

Experience with debridement and prosthesis retention in early prosthetic joint infections (PJI) due to Staphylococcus aureus is scarce. The present study aimed to evaluate the outcome and predictors of failure. Patients prospectively registered with an early PJI due to S. aureus and 2 years of follow-up were reviewed. Demographics, co-morbidity, type of implant, clinical manifestations, surgical treatment, antimicrobial therapy and outcome were recorded. Remission was defined when the patient had no symptoms of infection, the prosthesis was retained and C-reactive protein (CRP) was ≤1 mg/dL. Univariate and multivariate analysis were performed. Fifty-three patients with a mean ± SD age of 70 ± 10.8 years were reviewed. Thirty-five infections were on knee prosthesis and 18 were on hip prosthesis. The mean ± SD duration of intravenous and oral antibiotics was 10.6 ± 6.7 and 88 ± 45.9 days, respectively. After 2 years of follow-up, 40 (75.5%) patients were in remission. Variables independently associated with failure were the need for a second debridement (OR 20.4, 95% CI 2.3–166.6, p 0.006) and a CRP > 22 mg/dL (OR 9.8, 95% CI 1.5–62.5, p 0.01). The onset of the infection within the 25 days after joint arthroplasty was at the limit of significance (OR 8.3, 95% CI 0.8–85.6, p 0.07). Debridement followed by a short period of antibiotics is a reasonable treatment option in early PJI due to S. aureus. Predictors of failure were the need for a second debridement to control the infection a CRP > 22 mg/dL and the infection onset within the first 25 days after joint arthroplasty.

Background and Objective Allogeneic blood transfusion has been reported to increase the risk of postoperative infection in arthroplasty though the results are inconclusive. Data from a previous clinical trial on antibiotic prophylaxis in knee arthroplasty were analysed to gain further insight into the relationship between wound infection and both blood transfusion and the storage time of transfused RBCs. Materials and Methods A total of 910 consecutive patients undergoing primary knee arthroplasty were prospectively followed for 12 months after surgery. The main outcome was wound infection, either superficial or deep-tissue. Possible predictors for wound infection included the patient’s age and sex, preoperative physical status, time under leg ischaemia, postoperative fluid drainage, and the number and length of storage of transfused RBCs. Results Deep tissue infection was diagnosed in 28 (3%) patients, superficial infection in 25 (2·7%) and cellulitis in eight (0·8%) patients. Transfusion of at least one blood unit had been given to 22 (36%) of the 61 patients who later developed wound infection and 313 (36%) of those who did not (P > 0·05). Patients who developed wound infection had a significantly poorer physical status and longer time of leg ischaemia. There was no significant difference between both groups of patients in either the amount or the length of storage of transfused RBC units. Conclusion This study failed to find any association between the incidence of wound infection after knee arthroplasty and allogeneic transfusion.

The aim of our study was to evaluate the outcome of acute prosthetic joint infections (PJIs) due to gram-negative bacilli (GNB) treated without implant removal. Patients with an acute PJI due to GNB diagnosed from 2000 to 2007 were prospectively registered. Demographics, comorbidity, type of implant, microbiology data, surgical treatment, antimicrobial therapy, and outcome were recorded. Classification and regression tree analysis, the Kaplan-Meier survival method, and the Cox regression model were applied. Forty-seven patients were included. The mean age was 70.7 years, and there were 15 hip prostheses and 32 knee prostheses. The median number of days from the time of arthroplasty was 20. The most frequent pathogens were members of the Enterobacteriaceae family in 41 cases and Pseudomonas spp. in 20 cases. Among the Enterobacteriaceae , 14 were resistant to ciprofloxacin, while all Pseudomonas aeruginosa isolates were susceptible to ciprofloxacin. The median durations of intravenous and oral antibiotic treatment were 14 and 64 days, respectively. A total of 35 (74.5%) patients were in remission after a median follow-up of 463 days (interquartile range, 344 to 704) days. By use of the Kaplan-Meier survival curve, a C-reactive protein (CRP) concentration of ≤15 mg/dl ( P = 0.03) and receipt of a fluoroquinolone, when all GNB isolated were susceptible ( P = 0.0009), were associated with a better outcome. By use of a Cox regression model, a CRP concentration of ≤15 mg/dl (odds ratio [OR], 3.57; 95% confidence interval [CI], 1.05 to 12.5; P = 0.043) and receipt of a fluoroquinolone (OR, 9.09; 95% CI, 1.96 to 50; P = 0.005) were independently associated with better outcomes. Open debridement without removal of the implant had a success rate of 74.5%, and the factors associated with good prognosis were a CRP concentration at the time of diagnosis ≤15 mg/dl and treatment with a fluoroquinolone.

Debridement, irrigation and antibiotic treatment form the current approach in early prosthetic joint infection (PJI). Our aim was to design a score to predict patients with a higher risk of failure. From 1999 to 2014 early PJIs were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need for unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement. A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Treatment of 52 (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR 5.92, 95% CI 1.47–23.85), liver cirrhosis (OR 4.46, 95% CI 1.15–17.24), revision surgery (OR 4.34, 95% CI 1.34–14.04) or femoral neck fracture (OR 4.39, 95% CI1.16–16.62) compared with primary arthroplasty, C reactive protein >11.5 mg/dL (OR 12.308, 95% CI 4.56–33.19), cemented prosthesis (OR 8.71, 95% CI 1.95–38.97) and when all intraoperative cultures were positive (OR 6.30, 95% CI 1.84–21.53). A score for predicting the risk of failure was designed using preoperative factors (KLIC-score: Kidney, Liver, Index surgery, Cemented prosthesis and C-reactive protein value) and it ranged between 0 and 9.5 points. Patients with scores of ≤2, >2–3.5, 4–5, >5–6.5 and ≥7 had failure rates of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively. The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.

Background Measuring HRQOL is simple, inexpensive, permits the health status to be measured over time, and is useful to compare or initiate treatments and evaluate results, facilitating homogenization in patient inclusion. Objectives To evaluate disease-specific and generic HRQOL and influence of associated factors in patients undergoing open debridement for acute postsurgical knee prosthetic joint infection after TKR at 12 and 48 months after completing antibiotic treatment and considered cured of infection. Methods Health-related quality-of-life measures were administered at baseline (WOMAC) and 12 and 48 months (WOMAC and SF-36) in patients with prosthesis retention, no symptoms of infection, and CRP (≤ 1 mg/dL). Results Thirty patients were included, and 24 were evaluated at 48 months. WOMAC scores improved significantly (P

Patellar tendon rupture is an infrequent but debilitating lesion. Several surgical repairs have been suggested for patellar tendon rupture. Our aim is to propose a modified technique from the classic Achilles allograft procedure. Five consecutive patients diagnosed with chronic patellar tendon rupture following total knee arthroplasty (TKA) were included in the presented study. All patients were operated with a modified Achilles allograft technique, dividing the Achilles tendon into two bundles and overcrossing these through the distal part of the quadricipital tendon. All patients regained their extension mechanism and have discontinued using crutches. No complications were observed. The modified Achilles allograft has shown to be a safe, time-reducing repair for chronic patellar tendon ruptures following TKA, and should be considered as an alternative surgical repair.

It is important to know the spectrum of the microbial aetiology of prosthetic joint infections (PJIs) to guide empiric treatment and establish antimicrobial prophylaxis in joint replacements. There are no available data based on large contemporary patient cohorts. We sought to characterize the causative pathogens of PJIs and to evaluate trends in the microbial aetiology. We hypothesized that the frequency of antimicrobial-resistant organisms in PJIs has increased in the recent years. We performed a cohort study in 19 hospitals in Spain, from 2003 to 2012. For each 2-year period (2003-2004 to 2011-2012), the incidence of microorganisms causing PJIs and multidrug-resistant bacteria was assessed. Temporal trends over the study period were evaluated. We included 2524 consecutive adult patients with a diagnosis of PJI. A microbiological diagnosis was obtained for 2288 cases (90.6%). Staphylococci were the most common cause of infection (1492, 65.2%). However, a statistically significant rising linear trend was observed for the proportion of infections caused by Gram-negative bacilli, mainly due to the increase in the last 2-year period (25% in 2003-2004, 33.3% in 2011-2012; p 0.024 for trend). No particular species contributed disproportionally to this overall increase. The percentage of multidrug-resistant bacteria PJIs increased from 9.3% in 2003-2004 to 15.8% in 2011-2012 (p 0.008), mainly because of the significant rise in multidrug-resistant Gram-negative bacilli (from 5.3% in 2003-2004 to 8.2% in 2011-2012; p 0.032). The observed trends have important implications for the management of PJIs and prophylaxis in joint replacements. N. Benito, (C) 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Purposes To evaluate the specific characteristics, outcome, and predictors of failure of prosthetic joint infections (PJI) due to S. aureus and coagulase-negative staphylococci (CNS) treated with open debridement and retention of the implant. Methods PJI due to S. aureus or CNS prospectively registered in a database from 1999 to 2009 were retrospectively reviewed. During the study period, 106 patients met the inclusion criteria. The mean follow-up period was 3.8 years and for at least 2 years in all patients. The failure rate was 23.6% (25 out of 106). The only variable significantly associated with failure in the global cohort was polymicrobial infection (38.7% vs. 17.3%, p = 0.024). Fifty-seven (53.8%) patients had an infection due to S. aureus and 49 (46.2%) due to CNS. Among S. aureus infections, 95% corresponded to primary arthroplasties while 98% of PJIs due to CNS were after revision arthroplasties (pConclusions PJIs due to S. aureus were mainly in primary arthroplasties; they had a higher inflammatory response; and the strains were more susceptible to fluoroquinolones and methicillin than CNS infections. S. aureus infections had a higher failure rate than CNS infections, however, the difference was not statistically significant. There were few factors associated with failure and they were different in S. aureus and CNS infections.

Purposes To evaluate the long-term outcome (at least 4 years) of patients who underwent a surgical debridement due to an acute prosthetic joint infection (PJI) and to compare them with a control group that did not have an acute septic complication. Methods From January 1999 to December 2007, 61 patients with an acute PJI in remission after 2 years of follow-up (cases) were retrospectively reviewed and compared with a control group (2:1) without an acute PJI matched by age, year of arthroplasty, and type of prosthesis. Septic and aseptic complications of each group were gathered and compared using a chi-square test. A two-tailed p value Results Out of 183 patients, 4 cases and 2 controls were excluded due to death or lost to follow up; 113 (63.8%) were females and 109 (61.5%) had a knee replacement. The mean age and time of followup were 68.3 and 6.4 years, respectively. There were no statistically significant differences between cases and controls in the percentage of late septic or aseptic loosening. However, the late relapse rate in patients with acute PJI caused by S. aureus, was 12.5% (2 out of 16) and there was a trend towards significance when compared with the rest of the cohort (3.3%, p = 0.09). Aseptic late complications were more frequent in GN-cases (10.7%) than in the other groups (3.4% in GP-cases and 5% in controls) but this difference was not statistically significant (p = 0.19). Conclusions In conclusion, although analyzing all late complications together, patients with an acute PJI have a similar long-term outcome in comparison with controls; patients with an acute PJI due to S. aureus had a higher late relapse rate; and GN-cases developed an aseptic loosening more frequently. In the future, it is necessary to evaluate larger series to confirm our results.

Methicillin-resistant Staphylococcus is a common cause of orthopaedic implant infections. In such cases, rifampicin is the antibiotic of choice, but it should not be administered alone to avoid the selection of resistant mutants. Linezolid has activity against resistant staphylococci and a high oral bioavailability; therefore, it could be a good option for combining with rifampicin. We describe 2 patients admitted to our hospital due to orthopaedic implant infections, who received combination therapy with linezolid and rifampicin. In both cases, the trough serum concentration of linezolid during rifampicin treatment was below the minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC(90)) for staphylococci, but increased after rifampicin withdrawal. This finding suggests an interaction between rifampicin and linezolid, and a possible explanation is discussed.

Identifying the etiologic microorganism is essential to guide antimicrobial therapy in prosthetic joint infection.We (1) compared the frequency of positive cultures with synovial fluid inoculated in blood culture flasks (SF) with those of periprosthetic tissues or swabs in traditional cultures from patients with acute and chronic prosthetic joint infections (PJI) and (2) determined the sensitivity, specificity, and predictive values of the three methods.We retrospectively reviewed 87 patients with PJIs (54 knees, 33 hips) and 63 patients with aseptic loosening (34 knees, 29 hips). Two SF, periprosthetic tissue, and swab samples were taken for culture in all 150 patients except for 14 in whom only one SF fluid sample was obtained. Synovial fluid was inoculated in blood culture flasks and periprosthetic tissue and swab samples in standard media. Positive cultures were identified with standard biochemical procedures.SF samples were positive in 78 of 87 infected cases (90%), periprosthetic tissue samples were positive in 71 (82%), and swab samples were positive in 59 (68%). SF, periprosthetic tissue, and swab samples were positive more frequently in acute than in chronic infections (96% versus 82% for SF, 87% versus 74% for periprosthetic tissue, and 87% versus 44% for swabs). The sensitivity, specificity, and positive and negative predictive values of SF were 91, 100, 100, and 93 for acute infections and 79, 100, 100, and 88 for chronic infections, respectively.SF samples cultured in flasks had higher sensitivity, specificity, and positive and negative predictive values for diagnosis of PJI when compared with standard tissue and swab samples. The usefulness of all samples was less in chronic than in acute infections.Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

The aim of this study was to describe the prevalence and characteristics of knee prosthetic joint infections due to extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. From 2000 to 2007, 132 infections out of 5,076 arthroplasties (2.6%) were registered. Seven out of 132 infections (5.3%) were due to ESBL-producing Enterobacteriaceae, Escherichia coli in six cases and Klebsiella pneumoniae in one. Open debridement and retention of the implant was the first surgical approach and all patients received intravenous carbapenems. Relapse was documented in four cases and remission in three. Therefore, debridement without prosthesis removal was associated with a high failure rate.

Background There is no clinical trial analyzing the best moment to infuse an antibiotic during knee arthroplasty performed during ischemia. We designed a single-center, randomized, double-blind, placebo-controlled trial to evaluate whether antibiotic therapy should be administered before tourniquet inflation or just before tourniquet deflation. Material and methods Patients who underwent a primary knee arthroplasty were randomized to receive (1) 1.5 g of cefuroxime 10-30 min before inflation of the tourniquet and placebo 10 min before release of the tourniquet (standard arm) or (2) placebo 10-30 min before inflation of the tourniquet and 1.5 g of cefuroxime 10 min before release of the tourniquet (experimental arm). In both arms, a postoperative dose of 1.5 g of cefuroxime was given 6 h after the surgical procedure. The main variables associated with the rate of deep-tissue infection after 3 and 12 months of follow-up were gathered. Continuous variables were compared using Student's t test, and categorical variables were compared using the chi(2) test or Fisher's exact test. Results From September 2004 through December 2005, a total of 908 patients were randomized, 442 and 466 of whom were allocated to the standard and experimental arms, respectively. There were no differences between treatment arms in terms of age, sex, comorbidity, American Society of Anaesthesiologists score, duration of surgery, need of blood transfusion, or fourth-day hematocrit. The rates of deep-tissue infection among the standard and experimental groups were 3.4% and 1.9%, respectively, at 3 months of follow-up (P = .21) and 3.6% and 2.6%, respectively, at 12 months of follow-up (P = .44). Conclusion The administration of prophylactic antibiotics just before tourniquet release was not inferior to standard antibiotic prophylaxis.