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Background In difficult-to-treat cases, it is necessary to add debridement steps in prosthesis-free interval of 2-stage exchange. We aimed to analyze the functional and clinical outcome of patients treated with a multistage exchange of total hip arthroplasty without the use of spacers, rather only cementless implants. Methods Between 2009 and 2018, 84 patients (mean age: 67.3 [39-90] years) suffering chronic late-onset periprosthetic joint infection (PJI) were treated using a multistage prosthesis exchange without spacers. The mean follow-up was 70 ± 45.3 [14-210] months. The treatment included prosthesis exchange and at least 1 additional revision step before a reimplantation, owing to ongoing acute infection in the prosthesis-free interval. High-efficiency antimicrobial therapy was administered in between, which was discontinued after cementless revision implantation. Results The mean number of revisions between explantation and implantation was 2.6 (1-9). The most common microorganism was Staphylococcus epidermidis (53.6%) followed by Staphylococcus aureus (16.7%) and Cutibacterium acnes (11.9%). The bacterial load was more than one bacterium per patient in 38% of cases. All patients could be treated using a cementless implant. PJI remission was achieved in 92% of cases. Overall, 9 prostheses (11%) were replaced because of an ongoing PJI or fracture. The mean modified Harrison Hip Score was 63.4 (22-88) points. No patient died. Conclusion Multistage total hip arthroplasty exchange showed high remission rates and low mortality in difficult-to-treat cases. Spacer-free and multistage treatment had no negative effect on the success rate or functional outcome, consistent with the results of published 2-stage exchange studies. Implantation of an uncemented press-fit prosthesis was possible in all patients with no elevated periprosthetic fracture rate.

Surgical treatment using DAIR (debridement, systemic antibiotics, and implant retention) can lead to high rates of treatment success in cases of early periprosthetic joint infection (PJI) but can fail in late-onset cases. Supplementary local antibiotic therapy is not yet generally established and lacks evidence-based proof of efficacy. The aim of this study was to analyze DAIR outcomes in recurrent PJI cases and patients who are not suitable for a two-stage exchange, using additional degradable calcium-based antibiotics. All patients fulfilled the Infectious Diseases Society of America (IDSA) guidelines for chronic late-onset PJI but were not suitable for a multistage procedure because of their individual operation risk. A total of 42 patients (mean age, 73 years) were treated using a single-stage algorithm consisting of DAIR, followed by implantation of degradable antibiotics chosen in accordance with an antibiogram. OSTEOSET® (admixed ceftriaxone/vancomycin/tobramycin) and Herafill-Gentamycin® were used as carrier systems. The follow-up period was 23 months (± SD, 10.3). The study is based on institutional review board (IRB) approval. The clinical entities were chronic PJI of the hip (45.2%), knee (28.6%), and knee arthrodesis (26.2%). The bacterial spectrum was composed of Staphylococcus epidermidis (29%), Staphylococcus aureus (21%), and Enterococcus faecalis (21%). 21.4% showed a combination of two or more bacteria. In 73.8%, permanent remission was achieved, while 11.9% showed chronic PJI under implant retention. Implant retention could be achieved in 85.7%. DAIR usually shows low levels of success in difficult-to-treat cases. However, we could demonstrate the successful treatment of patients with recurrent PJI (typically considered DAIR-inappropriate) using degradable antibiogram-based topical calcium-based antibiotics. Over 70% of the cases went to remission and over 85% of the implants could be retained.

Background: Acute native septic arthritis is a joint-threatening emergency. To date, however, no gold-standard treatment nor joint-specific treatment algorithms exist. We aimed to evaluate the etio...

Infectious diseases of the skeleton have been known from the earliest stages of human development. Signs of burned-out osteomyelitis have been found in hominid fossils (Australopithecus africanus), and the symptoms are described in the oldest medical texts (Edwin Smith papyrus) (1– 3). Despite this, it has to this day proved impossible to identify definite criteria that would allow a reliable diagnosis. It is therefore very difficult to compare different investigation and treatment methods, and evidence-based results are few. The reason for this is the most important characteristic of the disease: the extreme variety of symptoms that can be manifested in chronic osteomyelitis. This variety makes a systematic description difficult; even experienced clinicians are repeatedly taken by surprise by new and unpredictable courses of the disease (4– 6). The clinical picture of chronic osteomyelitis has changed markedly in the past 70 years. With the arrival of antibiotics, it seemed at first to have lost its ability to inspire fear. In the industrialized countries, hematogenous osteomyelitis has been almost completely wiped out (7). The acquired post-traumatic/postoperative form, on the other hand, is on the increase. Because of the changing age structure of the population and the increasing number of surgical and orthopedic implantations, a further rise is expected in the near future (8, 9). For this reason, a review and explanation of current treatment concepts seems appropriate.