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Purpose: The two-stage exchange revision represents a pivotal strategy in the management of prosthetic joint infections, wherein the judicious timing of reimplantation serves as a crucial determinant for therapeutic success. At present, attempts have been made to utilize predictive models to establish the optimal timing for reimplantation; however, their predictive accuracy remains unsatisfactory. This inadequacy primarily arises from the lack of dependable predictive indicators, which demonstrate inconsistent effectiveness across various studies and occasionally yield contradictory outcomes. Therefore, identifying solid predictive indicators is in desperate need. Methods: Studies reporting outcomes of the two-stage exchange revision till June, 2023 were systematically retrieved, screened and subject to quality analysis. Basic characteristics of these studies were firstly summarized. Subsequently, factors of interest regarding clinical information, blood and body fluid test results, pathogen test results of the recurrent and recurrent-free cohorts were extracted and submitted to a fixed or random effects model. Meanwhile, evaluation of publication bias and sensitivity was performed. Results: After filtering, a total of 45 studies were finally involved. Pooled analysis suggested that the recurrent cohort exhibited elevated incidences of body mass index (BMI) > 30, smoking and alcohol habits, diabetes, sinus tract, positive culture, and G−, polymicrobial and drug-resistant infections. Additionally, higher levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), synovial white blood cell (WBC) count, and polymorphonuclear percentage (PMN%) were observed in the recurrent cohort. On the other hand, the results of D-dimer and fibrinogen were ambiguous, and no difference regarding peripheral WBC count was observed. Forest plots suggested a low risk of publication bias. Besides, sensitivity analysis indicated good stability of the aforementioned indicators, except D-dimer and fibrinogen. Conclusion: To sum up, BMI > 30, smoking and alcohol habits, diabetes, sinus tract, positive culture, and G-, polymicrobial and drug-resistant infections, CRP, ESR, synovial WBC and PMN% exhibited significant differences between recurrent and recurrent-free cohorts. Therefore, these indicators may be considered as potential predictive factors for the further development of a prognostic model that aids the determination of reimplantation timing. Nevertheless, the efficacy of these indicators remains to be further confirmed. Registration number: Prospero ID: CRD42022296568. [ABSTRACT FROM AUTHOR]

When treating chronic prosthetic joint infection after shoulder arthroplasty, removal of the implants and cement is typically pursued because they represent a potential nidus for infection. However, complete removal can increase morbidity and compromise bone stock that is important for achieving stable revision implants. The purpose of this study is to compare the rates of repeat infection after 2-stage revision for prosthetic joint infection in patients who have retained cement or hardware compared to those who had complete removal. We retrospectively analyzed all two-stage revision total shoulder arthroplasties performed for infection at 2 institutions between 2011 and 2020 with minimum 2-year follow-up from completion of the two-stage revision. Patients were included if they met the International Consensus Meeting criteria for probable or definite infection. Postoperative radiographs after the first-stage of the revision consisting of prosthesis and cement removal and placement of an antibiotic spacer were reviewed to evaluate for retained cement or hardware. Repeat infection was defined as either ≥2 positive cultures at the time of second-stage revision with the same organism cultured during the first-stage revision or repeat surgery for infection after the two-stage revision in patients that again met the International Consensus Meeting criteria for probable or definite infection. The rate of repeat infection among patients with retained cement or hardware was compared to the rate of infection among patients without retained cement or hardware. Thirty-seven patients met inclusion criteria and were included in the analysis. Six (16%) patients had retained cement and 1 patient (3%) had 2 retained broken glenoid baseplate screws after first-stage revision. Of the 10 cases of recurrent infection, 1 case (10%) involved retained cement/hardware. Age at revision (60.9 ± 10.6 vs. 65.0 ± 9.6, P =.264), body mass index (33.4 ± 7.2 vs. 29.7 ± 7.3, P =.184), Charlson Comorbidity Index (2 (0-8) vs. 3 (0-6), P =.289), male sex (7 vs. 16, P =.420), and presence of diabetes (1 vs. 3, P =.709) were not associated with repeat infection. Retained cement or hardware was also not associated with a repeat risk of infection (1 vs. 6, odds ratio = 0.389, P =.374). We did not find an increased risk of repeat infection in patients with retained cement or hardware compared to those without. Therefore, we believe that surgeons should consider leaving cement or hardware that is difficult to remove and may lead to increased morbidity and future complications. [ABSTRACT FROM AUTHOR]

Purpose of Review: Advancements in the management of bone and joint infections (BJIs) aim to improve outcomes while challenging long-standing treatment practices. This review discusses key updates, including use of oral antibiotics, shorter treatment durations, and novel approaches like phage therapy, as well as common clinical dilemmas, such as the role of rifampin. Recent Findings: Recent studies reinforce the benefits of oral antibiotics, as well as shorter durations of therapy in BJIs with supporting evidence. Long-acting lipoglycopeptides offer an alternative to traditional IV antibiotic courses, and emerging evidence establishes a role for phage therapy in difficult-to-treat infections. Studies evaluating use of rifampin in prosthetic joint infections have produced conflicting results, necessitating a risk–benefit analysis prior to use. Additional data is needed to elucidate the role of rifampin in diabetes-related foot osteomyelitis. Summary: Emerging therapeutic approaches are set to challenge conventional management practices in BJIs. Emphasis should be placed on integrating these approaches through antimicrobial stewardship initiatives. [ABSTRACT FROM AUTHOR]

Purpose: Two stage revision arthroplasty remains the gold standard for peri-prosthetic joint infections of the knee. However, the functional outcomes of revision surgeries and the factors governing them require further investigation. The purpose of this study was to (a) evaluate impact of early and late stage I surgery and interval between stage I and stage II; (b) understand the impact of infecting organism and resistance; (c) to estimate long term survivorship and causes of failure. Methods: A retrospective review of 86 patients, who underwent two stage revision for prosthetic joint infections of the knee, was performed. Time between onset of symptoms to stage I (T1), and T1 to re-implantation (T2), along with microbiological studies, were analysed for their impact on functional outcomes, failure modalities and survivorship. Results: In this study, the mean KSS-Knee improved from 64.0 ± 10.0 pre-operatively to 76.9 ± 10.4, and 77.2 ± 10.1 at the 5 and 10 year follow up respectively. The KSS-Function improved from 44.4 ± 8.8 pre-operatively to 72.2 ± 9.5 and 79.8 ± 8.1 at 5 and 10 year follow-up respectively. This study also found that T1 and T2 remained critical factors in determining functional outcome and longevity of the implant and a delay in these intervals was a significant predictor of failure. Gram negative, poly-microbial infections and organisms with methicillin and vancomycin resistance demonstrated lower survivorship (p-value, 0.001 at 5, 10 and 12 years). Re-infections occurred in 4 cases while 9 cases failed due to aseptic causes. Conclusion: Two-stage revision arthroplasty produced good functional outcomes when the infection was caused by single sensitive organism that did not exhibit high resistance to antibiotics. Stage I performed within 4 weeks and the subsequent re-implantation procedure undertaken within 6 weeks demonstrated better outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Calprotectin is a protein endowed with antimicrobial properties, rendering it a distinctive marker for infection. Two methods are currently available for the assay of calprotectin: the enzyme-linked immunosorbent assay (ELISA) and the lateral flow test (LFT). We aimed to assess the diagnostic accuracy of synovial fluid calprotectin and to compare the accuracy of the laboratory-based test and the qualitative assessment for the diagnosis of hip and knee prosthetic infection. Materials and methods: We searched (from inception to November 2023) MEDLINE, Scopus, EMBASE, Web of Science, and Cochrane for studies on calprotectin in the diagnosis of periprosthetic joint infection (PJI). Sensitivity, specificity, positive and negative likelihood ratio (LR), and diagnostic odds ratio were analyzed. The receiver-operating curve for each method was calculated. Results: We included 14 articles in our meta-analysis, including 902 patients who underwent total hip and knee arthroplasties revision; 331 (37%) had a joint infection according to MSIS, MSIS-modified criteria, ICM 2018 and EBJIS 2021. Considering the false-positive result rate of 6% and false-negative result rate of 7%, pooled sensitivity and specificity were 0.92 (95% CI 0.89–0.94) and 0.93 (0.91–0.95), respectively. The area under the curve (AUC) was 0.93 (95% CI 0.91–0.94). No statistical differences in terms of sensitivity and specificity were found between ELISA and LFT. The pooled sensitivity and specificity of the two calprotectin assessment methods were: LFT 0.90 (95% CI 0.869–0.935) and 0.92 (95% CI 0.894–0.941), respectively; ELISA 0.96 (95% CI 0.914–0.986) and 0.97 (95% CI 0.934–0.988), respectively. The diagnostic odds ratio of the ELISA was superior to that of the LFT (906.6667, 95% CI 271.2686–3030.3712 versus 113.8886, 95% CI 70.4001-184.2414; p < 0.001). The AUC for ELISA and LFT was 0.968 (95% CI 0.944–0.984) and 0.915 (95% CI 0.895–0.933), respectively. Conclusions: Detection of synovial calprotectin is an accurate test for diagnosis of hip and knee prosthetic infections. The diagnostic accuracy of the two calprotectin assessment methods is almost comparable. The LFT is a valid, rapid, and more available diagnostic tool, particularly to rule out PJI. [ABSTRACT FROM AUTHOR]

This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use. [ABSTRACT FROM AUTHOR]

In primary shoulder arthroplasty (SA), intravenous (IV) cefazolin has demonstrated lower rates of infectious complications when compared to IV vancomycin. However, previous analyses included SA cohorts with both complete and incomplete vancomycin administration. Therefore, it is currently unclear whether cefazolin still maintains a prophylactic advantage to vancomycin when it is appropriately indicated and sufficiently administered at the time of surgical incision. This study evaluated the comparative efficacy of cefazolin and complete vancomycin administration for surgical prophylaxis in primary shoulder arthroplasty with respect to infectious complications. A retrospective cohort study was conducted utilizing a single institution total joint registry database, where all primary SA types (hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse shoulder arthroplasty) performed between 2000 to 2019 for elective and trauma indications using IV cefazolin or complete vancomycin administration as the primary antibiotic prophylaxis were identified. Vancomycin was primarily indicated for patients with a severe self-reported penicillin or cephalosporin allergy and/or MRSA colonization. Complete administration was defined as at least 30 minutes of antibiotic infusion prior to incision. All included SA had at least 2 years of clinical follow-up. Multivariable Cox proportional hazard regression was used to evaluate all-cause infectious complications including survival free of prosthetic joint infection (PJI). The final cohort included 7177 primary SA, 6879 (95.8%) received IV cefazolin and 298 (4.2%) received complete vancomycin administration. Infectious complications occurred in 120 (1.7%) SA leading to 81 (1.1%) infectious reoperations. Of the infectious complications, 41 (0.6%) were superficial infections and 79 were (1.1%) PJIs. When categorized by administered antibiotics, there were no differences in rates of all infectious complications (1.6% vs. 2.3%; P =.352), superficial complications (0.5% vs. 1.3%; P =.071), PJI (1.1% vs. 1.0%; P =.874), or infectious reoperations (1.1% vs. 1.0%; P =.839). On multivariable analyses, complete vancomycin infusion demonstrated no difference in rates of infectious complications compared to cefazolin administration (hazard ratio [HR], 1.50 [95% confidence interval (CI), 0.70 to 3.25]; P =.297), even when other independent predictors of PJI (male sex, prior surgery, and Methicillin-resistant Staphylococcus aureus colonization) were considered. In comparison to cefazolin, complete administration of vancomycin (infusion to incision time greater than 30 minutes) as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should promote appropriate indications for the use of cefazolin or vancomycin, and when necessary, ensure complete administration of vancomycin to mitigate additional infectious risks after primary SA. [ABSTRACT FROM AUTHOR]

Rifampin is a crucial antibiotic in the management of prosthetic joint infections (PJI), particularly due to its effectiveness against staphylococcal bacteria and its ability to penetrate and disrupt biofilms. This review evaluates rifampin's role by examining its mechanism of action, clinical efficacy, and integration into treatment regimens based on recent evidence and guidelines. Rifampin's synergistic effects with other antibiotics, such as β-lactams and vancomycin, enhance bacterial eradication, and some evidence shows that it improves patient outcomes. However, evidence supporting its use is limited by the scarcity of robust human clinical trials, and challenges such as potential drug interactions and resistance development necessitate careful management. Ongoing research is needed to refine its use and address existing limitations in clinical practice. [ABSTRACT FROM AUTHOR]

Background: The microbiological profile of bone and joint infections is important for determining the empiric choice of both systemic and local antimicrobial therapy. This study assessed whether there was a difference in the bacterial species that were isolated on culture in osteomyelitis (OM), fracture-related infection (FRI) or prosthetic joint infection (PJI). This was a retrospective, observational cohort study of patients who had surgical intervention for PJI or OM or FRI with a positive microbial culture between 2019 and 2022. Methods: Data including patient demographics, the site of injury, JS-BACH score, organism classification and antibiotic resistance to vancomycin and gentamicin were extracted from the medical records. Results: A total of 440 patients were included in this study: 163 patients with osteomyelitis, 109 with fracture-related infection with fixation implants and 168 with prosthetic joint infection. The patients with PJI were older, more likely to be female and had a higher BMI and ASA score compared to those with OM. Patients with PJI were more likely to have a higher JS-BACH score and more complex infections. Staphylococcus aureus was the most commonly isolated organism in all three groups. It was more frequently isolated in osteomyelitis than in PJI (p = 0.016). In both osteomyelitis and FRI, after Staphylococcus aureus, the next most common organisms were Gram-negatives, whilst for PJIs, the most commonly isolated organisms were Staphylococcus aureus, followed by coagulase-negative Staphylococci and then Streptococcus species. The rates of other organisms were broadly similar between the three groups. When adjusted for confounders, including symptom duration, JS-BACH score, the location of injury, age and BMI, there was no statistically significant difference in the presence of Staphylococcus aureus (OR = 0.765; 95% CI 0.633–1.232; p = 0.465) or polymicrobial infection (OR = 1.175; 95% CI 0.803–1.721; p = 0.407). Conclusions: Causative pathogens are similar across bone and joint infections and are independent of the presence of prosthetic material. [ABSTRACT FROM AUTHOR]

Background: Non‐tuberculous mycobacteria (NTM) are rare causes of bone and joint infection (BJI) and there is limited evidence on which to base management decisions. This study describes 1 year of experience from a multi‐disciplinary BJI team which collects data on all cases reviewed at a tertiary referral centre in Queensland, Australia. Methods: The database was interrogated for all cases in which NTM were recovered from operative samples. Individual chart review was performed to collect the details of each case. Results: A total of seven cases were managed between 1st February 2021 and 28th February 2022, comprising one patient with chronic osteomyelitis, three with fracture‐related infections, two with prosthetic joint infections, and one with infection of a synthetic ligament graft. In contrast to pulmonary NTM infections, most patients were clinically well and immunocompetent, and most infections were propagated by direct inoculation. Time to diagnosis was unknown in three patients, with 1, 2, 2, and 5 months for the remaining four. Rapid growing NTM were diagnosed on routine cultures and specific mycobacterial cultures were confirmatory. Management was characterized by multiple stage surgical procedures and prolonged antimicrobial regimens. Conclusions: Antimicrobial complications were common; however, all patients were infection free at their latest follow up. Despite the inherent limitations, these results suggest that routinely ordering mycobacterial culture is of low yield. There is potential for shorter‐term oral antimicrobial treatments. Prospective research is required to optimize treatment regimens and durations. [ABSTRACT FROM AUTHOR]

Objectives Osteoarticular infection (OAI) is a feared complication of Staphylococcus aureus bacteraemia (SAB) and is associated with poor outcomes. We aimed to explore the risk of OAI and death following SAB in patients with and without rheumatoid arthritis (RA) and to identify risk factors for OAI in patients with RA. Methods Danish nationwide cohort study of all patients with microbiologically verified first-time SAB between 2006–18. We identified RA, SAB, comorbidities, and RA-related characteristics (e.g. orthopaedic implants and antirheumatic treatment) in national registries including the rheumatology registry DANBIO. We estimated the cumulative incidence of OAI and death and adjusted hazard ratios (HRs, multivariate Cox regression). Results We identified 18 274 patients with SAB (n  = 367 with RA). The 90-day cumulative incidence of OAI was 23.1% (95% CI 18.8; 27.6) for patients with RA and 12.5% (12.1; 13.0) for patients without RA (non-RA) [HR 1.93 (1.54; 2.41)]. For RA patients with orthopaedic implants cumulative incidence was 29.4% (22.9; 36.2) [HR 1.75 (1.08; 2.85)], and for current users of tumor necrosis factor inhibitors (TNFi) it was 41.9% (27.0; 56.1) [HR 2.27 (1.29; 3.98) compared with non-users]. All-cause 90-day mortality following SAB was similar in RA [35.4% (30.6; 40.3)] and non-RA [33.9% (33.2; 34.5), HR 1.04 (0.87; 1.24)]. Conclusion Following SAB, almost one in four patients with RA contracted OAI corresponding to a doubled risk compared with non-RA. In RA, orthopaedic implants and current TNFi use were associated with approximately doubled OAI risk. One in three died within 90 days in both RA and non-RA. These findings encourage vigilance in RA patients with SAB to avoid treatment delay of OAI. [ABSTRACT FROM AUTHOR]

Purpose of Review: Reverse shoulder arthroplasty (rTSA) is a commonly performed procedure to treat degenerative conditions of the shoulder. With its growing utilization, techniques to reliably diagnose and treat prosthetic joint infection (PJI) have become increasingly important. In this review we outline the current research and prevention methods of prosthetic joint infection in rTSA. This includes preoperative considerations, intraoperative, and postoperative treatment algorithms. Recent Findings: There is currently no established standardized protocol for preoperative infection prevention or post operative management. However, recent studies have identified risk factors for infection, as well as successful prevention techniques that can be implemented to minimize infection risk. Summary: Although there is no standardized protocol currently utilized to diagnose and treat shoulder PJI, we outline a potential set of preventative measures and postoperative management strategies that clinicians can use to properly diagnose and treat patients with this difficult condition. [ABSTRACT FROM AUTHOR]

Background: Revision total elbow arthroplasty (rTEA) remains a technically challenging procedure with potential for substantial morbidity. Cases involving excessively long cement mantles, removal of well-fixed implants or infected revisions requiring complete cement removal introduce additional technical challenges. Our purpose was to describe the outcomes, results, and complications associated with the use of cortical windows in rTEA. In addition, we provide a technical description of the procedure. Methods: rTEA cases utilizing a cortical window performed by two surgeons between 2019 and 2023 were reviewed. Baseline demographics and case characteristics were recorded. Preoperative and postoperative outcomes were compared, including range of motion, radiographic outcomes, surgical complications and patient-reported outcome measures. Results: Seven rTEA cases involving either a humeral or ulnar cortical window were included with an average follow-up of 15 months. Indications for cortical windows included infection, periprosthetic humerus fracture and presumed aseptic loosening. Improvements were noted postoperatively for pain scores, Quick Disabilities of the Arm, Shoulder and Hand and Single Assessment Numeric Evaluation elbow scores. Final flexion-extension and pronation-supination were 100° and 156°. One patient (14%) had a postoperative complication (failure of fixation of a periprosthetic humerus fracture). There were no cases of intraoperative iatrogenic fracture or nerve injury. Conclusion: For rTEA cases during which a cortical window was performed, complications occurred infrequently in the short term. In these challenging procedures, cortical windows appear to provide a relatively safe and efficient means of removing excessively long cement mantles or well-fixed components.

Revision total elbow arthroplasty (rTEA) is a technically challenging procedure that is associated with high rates of surgical complications. Cement removal remains an important and difficult component of rTEA. Particularly in the case of prosthetic joint infection following TEA, failure to remove all of the cement from the index procedure results in higher rates of recurrent or persistent infection. Options for cement removal include the use of nonpowered instruments, powered instruments, ultrasonic devices, arthroscopic-assisted techniques, bone episiotomies, and cortical windows. Carefully assessing the risks and benefits of each of these techniques can provide aid in both improving surgical efficiency and potentially reducing surgical morbidity during these complex procedures. The purpose of this narrative review was to explore technical aspects of cement removal for well-fixed implants during rTEA.

Abstract Background Prosthetic Joint Infection (PJI) is the most devastating complication of arthroplasty surgery and affects 1–5% of patients. Despite strict adherence to aseptic protocols and preventive measures, infection is the most common reason for revision arthroplasty, and the incidence is increasing. Treatment of PJI is challenging and often requires repeated major surgeries with sequentially poor results. The continued occurrence of PJI, and persistence after treatment, brings into question the current treatment paradigm. Preclinical evidence suggests a link between altered gut health and the risk of PJI in arthroplasty patients. Resistant starches helps to restore gut physiology by enhancing the beneficial microbiome and producing short-chain fatty acids, which have several health-conferring properties. The primary aim of this study is to investigate the effect of a commercially available prebiotic fibre formulation on the gut microbiome in PJI patients planned for a two-stage revision surgery. Methods A double-blind placebo-controlled trial will assess the effect of 8-week supplementation of a commercially available prebiotic supplement in patients presenting with first-time PJI undergoing two-stage revision surgery. The supplementation phase will start after the first stage revision, and 80 patients will be randomised to receive either a test product (34 g of resistant starch) or a placebo (custard powder) daily for eight weeks. Stool and blood specimens will be collected at baseline, four weeks and eight weeks after the first-stage surgery and once at second-stage surgery. Gut microbiome profile, inflammatory cytokines and gut permeability biomarkers will be measured. Tissue specimens will be collected intra-operatively during first and second-stage surgeries. Baseline dietary patterns and gut symptoms will be recorded using validated questionnaires. Treatment outcomes will be reported for both cohorts using the Delphi criterion at one and two years after second-stage surgery. Discussion This will be the first study to investigate the relationship between gut health optimisation and preventing PJI recurrence in arthroplasty patients. If supplementation with resistant starch improves gut health and reduces systemic inflammation, optimising the gut microbiome will be a recommended preoperative management strategy for arthroplasty patients. Trial registration no ACTRN12623001273673.

Abstract Background Prosthetic joint infections (PJI) are recalcitrant, hard-to-treat infections and severe complications of joint arthroplasty. Therefore, there is a need to develop new effective treatment strategies, and animal models of high clinical relevance are needed. This study aimed to develop a detailed surgical protocol for hip hemiarthroplasty in Göttingen minipigs and a thorough post-mortem sampling protocol to pave the way for creating a minipig PJI model. Methods Three adult female Göttingen minipigs underwent surgery with insertion of a hip hemiarthroplasty, using the anterior approach to the hip joint. After surgery the minipigs were followed closely with daily clinical evaluation and gait scoring. Comprehensive post-mortem analyses were performed with evaluation of macroscopic lesions, microbiology, synovial fluid analysis and histology. Results The study resulted in the first Göttingen minipig with hip hemiarthroplasty and identified several points of awareness when inserting a hip prosthesis in minipigs, especially the high risk of joint dislocation. A spontaneous PJI occurred in one of the minipigs, revealing an impaired ability of the immune cells to reach the bacteria at the bone-prosthesis interface. Conclusion The present study provides a detailed description of surgical technique and post-mortem sampling and validates the suitability of the hip hemiarthroplasty minipig model for future experimental modeling of PJI.

Abstract Background Staphylococci cause a wide range of infections, including implant-associated infections which are difficult to treat due to the presence of biofilms. Whilst some proteins involved in biofilm formation are known, the differences in biofilm production between staphylococcal species remains understudied. Currently biofilm formation by Staphylococcus aureus is better understood than other members of the genus as more research has focused on this species. Results We assembled a panel of 385 non-aureus Staphylococcus isolates of 19 species from a combination of clinical sources and reference strains. We used a high-throughput crystal violet assay to assess the biofilm forming ability of all strains and assign distinct biofilm formation categories. We compared the prevalence of Pfam domains between the categories and used machine learning to identify amino acid 20-mers linked to biofilm formation. This identified some domains within proteins already linked to biofilm formation and important domains not previously linked to biofilm formation in staphylococci. RT-qPCR confirmed the expression of selected genes predicted to encode important domains within biofilms in Staphylococcus epidermidis. The prevalence and distribution of biofilm associated domains showed a link to phylogeny, suggesting different Staphylococcus species have independently evolved different mechanisms of biofilm production. Conclusions This work has identified different routes to biofilm formation in diverse species of Staphylococcus and suggests independent evolution of biofilm has occurred multiple times across the genus. Understanding the mechanisms of biofilm formation in any given species is likely to require detailed study of relevant strains and the ability to generalise across the genus may be limited.

Background: Prosthetic Joint Infection (PJI) is the most devastating complication of arthroplasty surgery and affects 1–5% of patients. Despite strict adherence to aseptic protocols and preventive measures, infection is the most common reason for revision arthroplasty, and the incidence is increasing. Treatment of PJI is challenging and often requires repeated major surgeries with sequentially poor results. The continued occurrence of PJI, and persistence after treatment, brings into question the current treatment paradigm. Preclinical evidence suggests a link between altered gut health and the risk of PJI in arthroplasty patients. Resistant starches helps to restore gut physiology by enhancing the beneficial microbiome and producing short-chain fatty acids, which have several health-conferring properties. The primary aim of this study is to investigate the effect of a commercially available prebiotic fibre formulation on the gut microbiome in PJI patients planned for a two-stage revision surgery. Methods: A double-blind placebo-controlled trial will assess the effect of 8-week supplementation of a commercially available prebiotic supplement in patients presenting with first-time PJI undergoing two-stage revision surgery. The supplementation phase will start after the first stage revision, and 80 patients will be randomised to receive either a test product (34 g of resistant starch) or a placebo (custard powder) daily for eight weeks. Stool and blood specimens will be collected at baseline, four weeks and eight weeks after the first-stage surgery and once at second-stage surgery. Gut microbiome profile, inflammatory cytokines and gut permeability biomarkers will be measured. Tissue specimens will be collected intra-operatively during first and second-stage surgeries. Baseline dietary patterns and gut symptoms will be recorded using validated questionnaires. Treatment outcomes will be reported for both cohorts using the Delphi criterion at one and two years after second-stage surgery. Discussion: This will be the first study to investigate the relationship between gut health optimisation and preventing PJI recurrence in arthroplasty patients. If supplementation with resistant starch improves gut health and reduces systemic inflammation, optimising the gut microbiome will be a recommended preoperative management strategy for arthroplasty patients. Trial registration no: ACTRN12623001273673. [ABSTRACT FROM AUTHOR]

Suppressive antibiotic therapy is prescribed when a patient has an infection that is presumed to be incurable by a defined course of therapy or source control. The cohort receiving suppressive antibiotic therapy is typically highly comorbid and the infections often involve retained prosthetic material. In part due to a lack of clear guidelines regarding the use of suppressive antibiotics, and in part due to the complex nature of the infections in question, patients are often prescribed suppressive antibiotics for extremely long, if not indefinite, courses. The risks of prolonged antibiotic exposure in this context are not fully characterized, but they include adverse drug effects ranging from mild to severe, the development of antibiotic-resistant organisms, and perturbations of the gastrointestinal microbiome. In this narrative review we present the available evidence for the use of suppressive antibiotic therapy in 4 common indications, examine the gaps in the current literature, and explore the known and potential risks of this therapy. We also make suggestions for improving the quality of evidence in future studies, particularly by highlighting the need for a standardized term to describe the use of long courses of antibiotics to suppress hard-to-treat infections. [ABSTRACT FROM AUTHOR]

Prosthetic joint infections caused by Campylobacter are uncommon, with the majority of cases being attributed to C. fetus. This case report represents the third instance of a prosthetic hip infection caused by C. coli following an episode of gastroenteritis and, notably, in an immunocompetent patient. The infection was successfully managed by surgical debridement and lavage with retention of the prosthesis and 12 weeks of antibiotics. Furthermore, we present the first whole-genome sequence of a Campylobacter strain responsible for prosthetic joint infection and offer a comprehensive review of the literature on such infections. [ABSTRACT FROM AUTHOR]

Prosthetic joint infection (PJI) is a major complication following total arthroplasty. Rising antimicrobial resistance (AMR) to antibiotics will further increase therapeutic insufficiency. New antibacterial technologies are being developed to prevent PJI. In vivo models are still needed to bridge the translational gap to clinical implementation. Though rabbit models have been used most frequently, there is no consensus about methodology and measured outcomes. The PubMed, Scopus, and EMBASE databases were searched for literature on PJI in rabbit models. Data extraction included bias control, experimental design, and outcome measures of the NZW rabbit models in the articles. A total of 60 articles were included in this systematic literature review. The articles were divided into six groups based on the PJI intervention: no intervention used (21%), revision surgery (14%), prevention with only antibiotics (21%), prevention with surface modifications (7%), prevention with coatings (23%), and others (14%). Despite the current availability of guidelines and recommendations regarding experimental design, bias control, and outcome measures, many articles neglect to report on these matters. Ultimately, this analysis aims to assist researchers in determining suitable clinically relevant methodologies and outcome measures for in vivo PJI models using NZW rabbits to test new antimicrobial technologies. [ABSTRACT FROM AUTHOR]

Currently, despite advancements in diagnostic and therapeutic modalities, osteomyelitis and prosthetic joint infection (PJI) continue to pose significant challenges for orthopaedic surgeons. These challenges are primarily attributed to the high degree of heterogeneity exhibited by these disorders, which are influenced by a combination of environmental and host factors. Recent research efforts have delved into the pathogenesis of osteomyelitis and PJI by investigating single nucleotide polymorphisms (SNPs). This review comprehensively summarizes the current evidence regarding the associations between SNPs and the predisposition to osteomyelitis and PJI across diverse populations. The findings suggest potential linkages between SNPs in genes such as IL-1, IL-6, IFN-γ, TNF-α, VDR, tPA, CTSG, COX-2, MMP1, SLC11A1, Bax, NOS2, and NLRP3 with the development of osteomyelitis. Furthermore, SNPs in genes like IL-1, IL-6, TNF-α, MBL, OPG, RANK, and GCSFR are implicated in susceptibility to PJI. However, it is noted that most of these studies are single-center reports, lacking in-depth mechanistic research. To gain a more profound understanding of the roles played by various SNPs in the development of osteomyelitis and PJI, future multi-center studies and fundamental investigations are deemed necessary. [ABSTRACT FROM AUTHOR]

The management of prosthetic joint infections is a complex and multilayered process that is additionally complicated by the formation of bacterial biofilm. Foreign material provides the ideal grounds for the development of an intricate matrix that hinders treatment and creates a difficult environment for antibiotics to act. Surgical intervention is often warranted but requires appropriate adjunctive therapy. Despite available guidelines, several aspects of antibiotic therapy with antibiofilm activity lack clear definition. Given the escalating challenges posed by antimicrobial resistance, extended treatment durations, and tolerance issues, it is essential to ensure that antimicrobials with antibiofilm activity are both potent and diverse. Evidence of biofilm-active drugs is highlighted, and alternatives to classical regimens are further discussed. [ABSTRACT FROM AUTHOR]

Background: Intraosseous regional administration (IORA) as a widely applicable and clinically valuable route of administration has gained significant attention in the context of total knee arthroplasty (TKA) for the prophylactic administration of antibiotics. However, there is still controversy regarding its effectiveness and safety. The latest meta-analysis reports that the use of IORA for antibiotics in TKA is as safe and effective as IV administration in preventing prosthetic joint infection (PJI), but they did not separate the statistics for primary TKA and revision TKA, which may be inappropriate. There is currently a lack of evidence specifically comparing the outcomes of prophylactic antibiotic administration via IORA or IV route in primary/revision TKA, respectively, and new research evidence has emerged. Purposes: In this study, we conducted a systematic review and meta-analysis with the primary objective of comparing the local drug tissue concentration and the incidence of PJI between preoperative IORA and intravenous (IV) administration of prophylactic antibiotics in TKA. Additionally, the occurrence of complications between the two administration routes was also compared. Patients and Methods: This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) guidelines. Retrospective cohort studies and prospective randomized controlled trials that utilized intraosseous local drug delivery for prophylactic antibiotics in knee arthroplasty were included. English literature from PubMed, Embase, and Cochrane Library databases was searched from the inception of each database until December 2023. Two researchers independently screened the literature, assessed the quality, and extracted data according to the inclusion criteria. The primary outcomes were local antibiotic tissue concentration and postoperative PJI incidence, while the secondary outcome was the occurrence of postoperative complications. Statistical analysis was performed using Review Manager 5.3 software. Results: This study included 7 prospective randomized controlled trials and 5 retrospective cohort studies. A total of 4091 patients participated in the 12 included studies, with 1,801 cases receiving IORA and 2,290 cases in the control group. In terms of local drug tissue concentration, intraosseous infusion (IO) 500 mg vancomycin significantly increased the drug concentration in the periarticular adipose tissue (SMD: 1.36; 95% CI: 0.87–1.84; P < 0.001; I2 = 0%) and bone tissue (SMD: 0.94; 95% CI: 0.49–1.40; P < 0.001; I2 = 0%) compared to IV 1 g vancomycin. Regarding the incidence of postoperative PJI after primary TKA, IO 500 mg vancomycin was more effective in reducing the occurrence of PJI compared to IV 1 g vancomycin (OR: 0.19; 95% CI: 0.06–0.59; P < 0.001; I2 = 36%). Finally, no significant differences were found between the two groups in terms of postoperative pulmonary embolism (PE) (OR: 1.72; 95% CI: 0.22–13.69; P = 0.59; I2 = 0%) and vancomycin-related complications (OR: 0.54; 95% CI: 0.25–1.19; P = 0.44; I2 = 0%). Conclusions: Preoperative prophylactic antibiotic administration via IORA in TKA significantly increases local drug tissue concentration without significantly increasing systemic drug-related complications compared to traditional IV administration. In primary TKA, low-dose vancomycin via IORA is more effective in reducing the incidence of PJI compared to traditional IV regimens. However, its effectiveness remains controversial in high-risk populations for PJI, such as obese, diabetic, and renal insufficiency patients, as well as in revision TKA. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infection (PJI) can be a serious complication of total knee arthroplasty (TKA). A method believed to decrease the incidence of PJI is antibiotic-laden bone cement (ALBC). Current clinical practice guidelines do not recommend ALBC in primary TKA. The purpose of this study was to compare ALBC to plain cement (PC) in preventing PJI in primary TKA. This retrospective analysis included 109,242 Medicare patients in the American Joint Replacement Registry who underwent a cemented primary TKA from January 2017 to March 2021, and had at least 1 year of follow-up. Patients who received ALBC were compared to patients who received PC. Demographic and case-specific variables such as age, sex, race, body mass index, Charlson Comorbidity Index, anesthesia type, and operative time were used to create propensity scores. A logistic regression was run to predict the probability of receiving ALBC. Also, a multivariate model was run on the full unstratified population, using the same covariates as were used to create the propensity model. The primary outcome was differences in PJI rates. Logistic regression analysis showed that a higher preoperative diagnosis of osteoarthritis, higher Charlson Comorbidity Index, higher body mass index, women, race, and anesthesia requirements increased a patient's probability of receiving ALBC. In the full unstratified multivariate model, ALBC did not show a statistically significant difference in risk of revision for infection compared to PC. The use of ALBC in primary TKA has not been shown to be more efficacious in preventing PJI within the population of Medicare patients in the United States. However, this study is limited given it is a retrospective database study that may inherently have biases and the large dataset has a potential for overpowering the findings. [ABSTRACT FROM AUTHOR]

The purpose of this retrospective analysis of a prospective quality control project was to determine whether the use of intrawound vancomycin powder (IVP) decreases the rate of periprosthetic joint infection (PJI) within 90 days following primary total hip arthroplasty (THA). From October 2021 to September 2022, a prospective quality control project was undertaken in which 10 high-volume THA surgeons alternated between using and not using IVP each month while keeping other perioperative protocols unchanged. A retrospective analysis of the project was performed to compare the group of patients who received IVP to the group of patients who did not. The primary outcome was a culture positive infection within 90 days following primary THA. Secondary outcomes included gram-positive culture, overall reoperation rate, wound complications, readmission, and wound complications within 90 days post-operatively. A total of 1,193 primary THA patients were identified for analysis. There were 523 (43.8%) patients who received IVP and were included in the IVP group, while 670 (56.2%) did not and were included in the non-IVP group. Age, body mass index, and sex were similar between the 2 groups (P >.25). The IVP group had a higher rate of culture positive joint infections (1.7 [0.8, 3.2] versus 0.3% [0.04, 1.1], P =.01) than the non-IVP group. All PJI's were found to have gram positive bacteria in both groups. The IVP group had a higher overall reoperation rate than the non-IVP group (6.1 [4.2, 8.5] versus 2.4% [1.4, 3.9], P <.01). The IVP group had a higher reoperation rate for any wound complication compared to non-IVP patients (2.7 [1.5, 4.5] versus 0.7% [0.2, 1.7], P <.01). The overall readmission rate (6.1 [4.2, 8.5] versus 2.8% [1.7, 4.4], P <.01), as well as readmission for suspected infection (2.1 [1.1, 3.7] versus 0.6% [0.02, 1.5], P =.03), were higher in the IVP group. The use of IVP in primary THA was associated with a higher rate of PJI, overall reoperation, reoperation for wound complications, and readmission in a prospective quality control project. Until future prospective randomized studies determine the safety and efficacy of IVP in THA conclusively, we advocate against its utilization. [ABSTRACT FROM AUTHOR]

Chlorhexidine gluconate (CHG) and povidone-iodine (PI) are commonly used to prevent prosthetic joint infection (PJI) during total joint replacement; however, their effective concentrations and impact on biofilms are not well defined. To determine: (1) the in-vitro minimum inhibitory concentration of CHG and PI against model PJI-causing organisms and clinical isolates; (2) their impact on biofilm formation; (3) whether there is a synergistic benefit to combining the two solutions; and (4) whether adding the antibiotic vancomycin impacts antiseptic activity. We measured in-vitro growth and biofilm formation of Staphylococcus epidermidis , meticillin-sensitive and meticillin-resistant Staphylococcus aureus , Escherichia coli , Pseudomonas aeruginosa and Candida albicans , as well as recent clinical isolates, in the presence of increasing concentrations of CHG and/or PI. Checkerboard assays were used to measure potential synergy of the solutions together and with vancomycin. CHG and PI inhibited growth and biofilm formation of all model organisms tested at concentrations of 0.0004% and 0.33% or lower, respectively; highly dilute concentrations paradoxically increased biofilm formation. The solutions did not synergize with one another and acted independently of vancomycin. CHG and PI are effective at lower concentrations than typically used, establishing baselines to support further clinical trials aimed at optimizing wound disinfection. There is no synergistic advantage to using both in combination. Vancomycin is effective at inhibiting the growth of S. epidermidis and S. aureus ; however, it stimulates P. aeruginosa biofilm production, suggesting in the rare case of P. aeruginosa PJI, it could exacerbate infection. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infections (PJIs) continue to be a complication that plagues arthroplasty. Albumin is a surrogate marker for nutrition as well as chronic inflammation, and hypoalbuminemia increases the risk of complications in arthroplasty. Patients with PJI are at increased risk for malnutrition and complications. This study's objective was to analyze patients who underwent treatment of PJI following total hip arthroplasty and investigate the outcome with regards to albumin levels. Overall, 48 patients who underwent surgery for a total hip PJI at 1 institution were reviewed. Albumin and C-reactive protein were recorded preoperatively and 2 to 3 weeks postoperatively. Treatment failure was determined by further surgical treatment for PJI or repeat infection, as determined by Musculoskeletal Infection Society guidelines. A debridement, antibiotics, and implant retention procedure was performed in 39 patients, and explant with the placement of an antibiotic spacer was performed in 9. Preoperative mean albumin levels were significantly decreased in patients who failed to clear their infection compared to patients who remained infection-free (2.5 versus 3.3, P <.001). Postoperative albumin levels decreased in this same population (2.6 versus 3.8, P <.001). C-reactive protein was elevated in patients who failed to clear their infection preoperatively (19.9 versus 7.5, P <.001) and postoperatively (7.0 versus 1.7, P <.001). The average time to repeat surgical treatment for their PJI was 9 months Lower albumin levels are observed in patients with PJI who failed to remain infection-free after surgery. Albumin is a surrogate marker for nutrition, and low albumin is associated with poor immune function. Hypoalbuminemia is found with chronic inflammation as well as malnutrition. Nutritional reserves are diverted to the acute inflammatory response during an infection, which can lead to a deficient state. Further research may develop treatments to alter this modifiable risk factor. Level 4. [ABSTRACT FROM AUTHOR]

Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood. A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P <.05. A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P <.0001) with higher ASA scores (P <.0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P =.0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P =.0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts. Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible. [ABSTRACT FROM AUTHOR]

Synovial fluid analysis is important in diagnosing prosthetic joint infection (PJI). The rate of culture-positive PJI in patients who have a dry tap of a total hip arthroplasty (THA) is not well described. We reviewed all image-guided THA aspirations, performed from 2014 to 2021 at a single academic institution. Aspirations were categorized as successful (≥ 0.5 mL) or unsuccessful (< 0.5 mL, "dry tap"). We analyzed culture data on all repeat aspirations and revision surgeries performed within 90 days of the initial dry tap. We reviewed 275 consecutive attempted THA aspirations of which 100 (36.4%) resulted in a dry tap. The dry tap cohort had a significantly higher percentage of fluoroscopic-guided aspirations (64%) and fewer ultrasound-guided aspirations (36%) compared to the successful aspiration cohort (48.9% fluoroscopic, 53.1% ultrasound, P =.0061). Of the 100 patients who have dry taps, 48 underwent revision surgery within 90 days of the initial dry tap, and 15 resulted in 2 or more positive cultures. The rate of PJI defined by MusculoSkeletal Infection Society major criteria in the dry tap cohort was 16.0%. Attempted aspiration of a THA resulted in a dry tap 36.4% of the time. Of those patients who had a dry tap, 16.0% were subsequently found to have PJI based on MusculoSkeletal Infection Society major criteria. Therefore, a "dry tap" does not exclude the diagnosis of infection and should not be considered reassuring for the absence of PJI. [ABSTRACT FROM AUTHOR]

Sterile surgical helmet systems are frequently utilized in total knee arthroplasty procedures to protect the surgeon while maintaining a comfortable working environment. However, common helmet systems pressurize the space between the surgical gown and the surgeon's skin. In gowns with a back seam, this may allow contaminated skin particles to escape into the surgical field. By measuring bacterial colony-forming units (CFUs), this study sought to determine if occlusion of the open back seam reduced the risk of potential contamination. First, qualitative analysis depicting airflow variations between gown configurations was performed using the Schlieren Spherical Mirror imaging system. Each gown configuration consisted of a sterile surgical helmet and one of 3 gown configurations: a standard gown with rear-tied closure, a standard gown with a surgical vest, and a zippered Toga-style gown. Next, a surgeon then performed simulated surgical activities for 60 minutes within a 1.4 m3 isolation chamber with work surfaces and controllable filtered air exchanges. During each procedure, contaminated particles were collected on sets of agar settle plates positioned directly behind the surgeon. Upon completion, the agar plates were incubated in a biolab, and the number of bacterial and fungal CFUs was counted. The experimental procedure was repeated 12 times for each gown configuration, with sterilization of the chamber between runs. Contamination rates were expressed as CFUs/m2/h. The mean contamination rate measured with the standard gown was 331.7 ± 52.0 CFU/m2/h. After the addition of a surgical vest, this rate decreased by 45% to 182.2 ± 30.8 CFU/m2/h (P =.02). Similarly, with the Toga-style gown, contamination rates dropped by 49% to 170.5 ± 41.9 CFU/m2/h (P =.01). When used in conjunction with surgical helmet systems, conventional surgical gowns do not prevent potential contamination of the surgical field. We recommend that staff within the surgical field cover the back seam of standard gowns with a vest or don a zippered Toga-style gown. [ABSTRACT FROM AUTHOR]

Background: Staphylococci cause a wide range of infections, including implant-associated infections which are difficult to treat due to the presence of biofilms. Whilst some proteins involved in biofilm formation are known, the differences in biofilm production between staphylococcal species remains understudied. Currently biofilm formation by Staphylococcus aureus is better understood than other members of the genus as more research has focused on this species. Results: We assembled a panel of 385 non-aureus Staphylococcus isolates of 19 species from a combination of clinical sources and reference strains. We used a high-throughput crystal violet assay to assess the biofilm forming ability of all strains and assign distinct biofilm formation categories. We compared the prevalence of Pfam domains between the categories and used machine learning to identify amino acid 20-mers linked to biofilm formation. This identified some domains within proteins already linked to biofilm formation and important domains not previously linked to biofilm formation in staphylococci. RT-qPCR confirmed the expression of selected genes predicted to encode important domains within biofilms in Staphylococcus epidermidis. The prevalence and distribution of biofilm associated domains showed a link to phylogeny, suggesting different Staphylococcus species have independently evolved different mechanisms of biofilm production. Conclusions: This work has identified different routes to biofilm formation in diverse species of Staphylococcus and suggests independent evolution of biofilm has occurred multiple times across the genus. Understanding the mechanisms of biofilm formation in any given species is likely to require detailed study of relevant strains and the ability to generalise across the genus may be limited. [ABSTRACT FROM AUTHOR]

Background: Periprosthetic joint infections (PJI) are among the most morbid complications in total hip arthroplasty (THA). The ideal incubation time, however, for intraoperative cultures for PJI diagnosis remains unclear. As such, the aim of this study was to determine if any differences existed in culture-positive rates and organism detection between five-day and fourteen-day cultures. Methods: This retrospective cohort study consisted of THA cases diagnosed with PJI performed between May 2014 and May 2020 at a single tertiary-care institution. Analyses compared five-day and fourteen-day cultures and carried out a pre-specified subgroup analysis by organism and PJI type. Results: A total of 147 surgeries were performed in 101 patients (57.1% females), of which 65% (n = 98) obtained five-day cultures and 34% (n = 49) obtained fourteen-day cultures. The positive culture rate was 67.3% (n = 99) with Staphylococcus aureus being the most common pathogen identified (n = 41 specimens, 41.4%). The positive culture rate was not significantly different between groups (66.3% five-day, 69.4% fourteen-day, p = 0.852). Fourteen-day cultures had a significantly longer time-to-positive culture (5.0 days) than five-day cultures (3.0 days, p < 0.001), a higher rate of fungi (5.6% vs. 0%), and a lower rate of Gram-negatives (4.5% vs. 18.7%, p = 0.016). Conclusions: Fourteen-day cultures did not increase the positivity rate, had higher rates of slow-growth pathogens, and had a longer time-to-positivization than five-day cultures. Prolonged culture holds may provide more thorough organism detection for PJI without increasing the diagnostic culture yield. [ABSTRACT FROM AUTHOR]

Complex surgical site infections (SSIs) and revisions for these infectious complications following total knee and hip arthroplasties are associated with significant economic costs. To evaluate the cost of one-stage and two-stage revision; debridement, antibiotics and implant retention (DAIR); and DAIR with liner exchange for complex hip or knee SSIs in Alberta, Canada. The Alberta Health Services Infection Prevention and Control database was used to identify individuals aged ≥18 years from the two major urban centres in Alberta – Calgary and Edmonton – with complex hip or knee SSIs who underwent surgical intervention between 1st April 2012 and 31st March 2019. Micro-costing and gross costing methods were used to estimate 12- and 24-month costs following the initial hospital admission for arthroplasty. Subgroup, inverse Gaussian and gamma regression analyses were used to evaluate associations between cost and revision procedure, age, sex and comorbidities. In total, 382 patients with complex SSIs were identified, with a mean age of 66.1 years. DAIR and DAIR with liner exchange resulted in the lowest 12- and 24-month costs at $53,197 [95% confidence interval (CI) $38,006–68,388] and $57,340 (95% CI $48,576–66,105), respectively; two-stage revision was the costliest procedure. Most of the costs incurred (>98%) were accrued within the first 12 months following the initial procedure. Medical costs are highest in the 12 months following initial arthroplasty, and for two-stage revision procedures in hip and knee complex SSIs. [ABSTRACT FROM AUTHOR]

Increasing antibiotic resistance has been reported as an issue in the treatment of periprosthetic joint infection (PJI). A repeat two-stage revision for recurrent PJI is at high risk of reinfection. However, it is unclear if the microorganism profile plays a role with potentially more resistant or polymicrobial infections. This is a retrospective, single-center analysis of two-stage revisions performed between 2011 and 2017. We identified 46 patients who underwent a repeat resection arthroplasty for recurrent PJI of the same joint after a previous two-stage revision of the same joint at the same department. All microbiological findings were analyzed focusing on microbiological spectrum and resistance testing as well as the potential impact on reinfection-free survival. The most common organism found at the time of recurrent PJI were coagulase-negative Staphylococci (39%) followed by Gram-negative organisms (28%). The risk of polymicrobial infections, difficult-to-treat resistant organisms, and Gram-negative infections increased significantly. Among staphylococcal infections, there was a high percentage of methicillin-resistant species and resistance to oral antibiotics. Patients with Gram-negative organisms had a reduced infection-free survivorship, while resistant organisms were not associated with decreased survival. Patients who undergo a repeat two-stage revision for recurrent PJI have more polymicrobial and resistant organisms, although the impact on survivorship is unclear. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

PURPOSE OF REVIEW: Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty. RECENT FINDINGS: The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

Prosthetic joint infections (PJIs) following total joint arthroplasties are relatively rare but devastating complications. To date, no cases of Mycobacterium fortuitum PJIs associated with contaminated water supplies have been reported in the literature. Our report details 5 patients with Mycobacterium fortuitum PJIs related to a contaminated water supply at an ambulatory surgical center. These patients were identified by referral to our academic center. All underwent at least 1 revision surgery prior to referral and required prolonged broad-spectrum antibiotics. All had extensive wound complications, and 4 of 5 patients have received at least stage 1 of a 2-stage revision. All will require further surgery, but long-term outcomes remain relatively uncertain.

Background: Periprosthetic joint infections (PJIs) are a serious complication after total joint arthroplasty. Our study aimed to analyze the characteristics and research highlights of the top 100 most cited studies on PJI from an orthopaedic standpoint. Moreover, we sought to assess whether there has been a change in the level of evidence (LOE) throughout time. Methods: We conducted a search of the PubMed, Embase, and Web of Science databases to identify the top 100 studies primarily focusing on PJI. Study characteristics assessed included publication year, LOE, journal of publication, and type of study. Research highlights of the included studies were classified into 6 sections. Linear regression was employed to assess correlation between LOE and publication year. Results: The aggregated citation count of all studies was 19,558 and the median citation number was 129.5. While cohort studies were the most prevalent, articles focusing on analysis of costs associated with PJI care or PJI definition garnered the highest yearly citation counts. The bulk of included studies were concentrated in 3 orthopaedic journals and published in the 2010s. The majority of studies had a LOE II (30%) or III (34%). On regression analysis, LOE was not correlated with publication year (Pearson’s r = 0.013, P = .61). Conclusions: The most cited PJI articles assessed the definition of PJI and PJI cost. Despite growing interest in PJI, the majority of studies had LOE II or III, highlighting the difficulty of conducting prospective randomized controlled trials in PJI patients. Level of evidence: IV.

ABSTRACT Local delivery of antibiotics as prophylaxis for prosthetic joint infections (PJIs) is frequently used during total hip replacement surgery. Morselized bone allograft impregnated with vancomycin and tobramycin (TobraVanc) could provide effective prophylaxis against bacteria commonly associated with PJIs. In this study, the concentrations of antibiotics released by bone allograft impregnated with TobraVanc were determined by using an in vitro bioassay system entailing measuring inhibition zone diameters caused by antibiotic-impregnated bone chips cast in agar against standard curves. The concentrations were determined in samples of TobraVanc-impregnated bone graft taken before and after the application of the bone graft in the patients undergoing acetabular revision surgery. Antibiotic-impregnated bone grafts, sampled prior to application in the patient, delivered antibiotics in the concentration ranges of 730–9,800 mg/L for tobramycin and 1,300–11,000 mg/L for vancomycin. Samples taken after application in the patient released lower concentrations of tobramycin (490–1,900 mg/L; P < 0.01) and vancomycin (3,000–5,100 mg/L; P < 0.05); however, these concentrations remained well above the tobramycin minimum inhibitory concentrations (MICs) for investigated, highly tobramycin-resistant Staphylococcus epidermidis strains (MICs > 256 mg/L). At the tested concentrations, bone graft material mixed with TobraVanc delivered antibiotics in potent concentrations above the MICs for bacteria causing PJIs. Clinical trials are needed to evaluate the efficacy and risk of TobraVanc-impregnated bone graft as a prophylactic agent for patients undergoing hip replacement surgery.IMPORTANCEAntibiotic prophylaxis is the cornerstone of successful joint replacement surgery, reducing the risk for the dreaded complication of prosthetic joint infection (PJI) to roughly 0.5%–2% in standard total hip replacement (THR). In addition to systemic antibiotics, antibiotics added locally have the potential to reduce the PJI risk even further, because of the high concentrations that can be achieved in the joint with limited risk for systemic toxicity. The results in the current study show that bone chips impregnated with a combination of tobramycin and vancomycin (TobraVanc) release antibiotics in concentrations that are potent against common bacteria causing PJIs. Especially in high-risk patients, our results support the prophylactic use of TobraVanc in hip replacement surgery requiring the use of a bone graft. A clinical study testing the efficacy of TobraVanc-impregnated bone graft in reducing the incidence of PJI in hip replacement surgery is currently ongoing (EudraCT: 2021-001708-14).

Background: Prosthetic Joint Infection (PJI) is a serious complication after total hip arthroplasty (THA). PJI is the most common reason for revision surgery on patients with arthroplasty, leading to prolonged hospitalization, repeated surgical intervention, and sometimes in definitive loss of the implant. Clostridium perfringens causing PJI is highly unusual. Case report: In this case, we describe the diagnostic and therapeutic challenges of a Clostridium perfringens Prosthetic Joint Infection following a total hip arthroplasty in an elderly woman. Conclusion: This case is unique because it is the first published PJI with C. perfringens, successfully treated by a one-stage infection revision combined with twelve weeks of antibiotics. Despite an extensive work up, a PJI or C. perfringens infection was not proven preoperatively. Perioperative tissue and sonication cultures were the cornerstone of the diagnosis. C. perfringens may be seen as an ‘easy to treat’ pathogen and successful treatment is possible with a one-stage infection revision and additional antibiotics for twelve weeks.