Deep Periprosthetic Joint Infection Research Articles

Infection Rates After Aseptic Revision Total Hip Arthroplasty With Extended Oral Antibiotic Prophylaxis.

Few US studies have investigated the efficacy of extended oral antibiotic prophylaxis (EOAP) in the prevention of periprosthetic joint infection (PJI) after aseptic revision total hip arthroplasty (R-THA). This study compared PJI rates in aseptic R-THA performed with EOAP with PJI rates in published studies of aseptic R-THA patients not receiving EOAP. Prospectively documented data on 127 consecutive aseptic R-THAs were retrospectively reviewed. Evidence-based perioperative infection prevention protocols were used, and all patients were discharged on 7-day EOAP. Superficial and deep infections at 30 and 90 days postoperatively and at mean latest follow-up of 27.8 months were statistically compared with all US studies reporting the prevalence of PJI after aseptic R-THA. Complications related to EOAP within 120 days of the index procedure also are reported. No superficial or deep infections were observed at 30 and 90 days postoperatively when 7-day postdischarge EOAP was used. Superficial and deep infection rates were 1.57% (two patients) and 3.15% (four patients) at mean latest follow-up, respectively. Comparisons with published 30-day PJI rates of 1.37% ( P = 0.423) and 1.85% ( P = 0.257) were not statistically significant. Two of four comparisons with published 90-day PJI rates of 3.43% ( P = 0.027) and 5.74% ( P = 0.001) were statistically different. The deep PJI rate of 3.15% at mean latest follow-up was significantly lower than two of three published rates at equivalent follow-up including 10.10% ( P = 0.009) and 9.12% ( P = 0.041). No antibiotic-related complications were observed within 120 days of the index procedure. Study findings possibly support the use of EOAP after aseptic R-THA to prevent catastrophic PJI with revision implants, indicating that the efficacy of EOAP cannot be definitively ruled-in or ruled-out based on available evidence.

Total Knee Arthroplasty in Hemodialysis Patients: Routine or Complex Surgery?

Background. Chronic hemodialysis significantly increases the risks associated with knee replacement. Among the late complications of knee arthroplasty in hemodialysis patients, deep periprosthetic joint infection (PJI) and aseptic loosening are more frequent. The frequency of revision interventions in patients with end-stage kidney disease (ESKD) is substantially higher compared to patients with normal kidney function.
 The aim of the study — based on the perioperative parameters and midterm outcomes to justify the primary knee replacement in chronic hemodialysis patients as complex case of arthroplasty.
 Methods. A retrospective randomized single-center cohort study was conducted, including 62 patients with various forms of knee osteoarthritis. Patients were divided into two groups: Group 1 — 29 (46.8%) patients with end-stage renal disease (ESRD) undergoing dialysis, Group 2 — 33 (53.2%) patients without kidney pathology. The average follow-up period in both groups was 3.7 years (min — 1, max — 6). The following parameters were assessed: patient age, length of hospital stay, morphocortical index, body mass index (BMI), duration of hemodialysis, functional assessment of the knee joint using the KSS Function Score and Forgotten Joint Score-12 (FJS-12), radiological results on the KRESS, and the frequency of various complications.
 Results. In Group 1, patients had significantly lower BMI compared to Group 2. Length of hospital stay in Group 1 were 1.7 times longer. According to the KSS Function Score, no significant differences were observed between the groups in the first 36 months after the operation. However, by the 4th year of follow-up, average KSS Function Score in Group 1 decreased to 77.3 points, which was due to infectious complications. The FJS-12 showed worse scores in Group 2, averaging 68.7 points. After more than three years post-operation, no statistically significant differences were observed between the groups, which was associated with an increase in the number of complications in Group 1. Results on the KRESS after 43 months did not differ between the groups and averaged 4.8 points. Group 1 had more orthopedic complications and cases of PJI, accounting for 7 out of 37.
 Conclusion. Age and constitutional characteristics of patients undergoing hemodialysis significantly differ from the normal population. The frequency of complications in Group 1 was 23.5%. These patients require the implantation of more constrained implant components and modular systems. Therefore, primary knee replacement in hemodialysis patients can be classified as a complex case of arthroplasty.

Systemic Manifestation of Periprosthetic Joint Infection Is Associated With Increased In-Hospital Mortality.

Introduction Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty. Systemic symptoms of infection may indicate a patient who is at a higher risk of serious complications. The goal of this study was to determine if systemic symptoms of infection in the setting of PJI were associated with greater in-hospital mortality. Materials and methods We used our institutional database to identify all patients urgently treated for deep PJI from 2002-2012. Records were reviewed to collect demographics, surgical data, vital signs prior to surgical intervention, blood and intraoperative culture results, preoperative intensive care unit (ICU) admissions, and deaths that occurred during the hospital admission. Patients were classified as having systemic inflammatory response syndrome (SIRS) based on the criteria established by the American College of Chest Physicians and the Society of Critical Care Medicine. Results During the 10-year timeframe of our study, 484 patients were treated emergently for deep infection, with 130 (27%) meeting SIRS criteria preoperatively and 31 (6%) of the patients with SIRS having positive blood cultures. Patients with positive blood cultures and SIRS demonstrated a higher in-hospital mortality rate (p < 0.001). Neither SIRSnor SIRS with positive blood cultures were associated with ICU admission. Discussion Occasionally, PJI can spread beyond the affected joint, showing physical symptoms of systemic illness and bacteremia. This study demonstrates that patients with SIRS and positive blood cultures are at an increased risk of in-hospital mortality. These patients should be monitored closely before definitive treatment in order to minimize their mortality risk.

Modern Technologies in the First Stage Treatment of Deep Periprosthetic Hip Joint Infection

Modern Technologies in the First Stage Treatment of Deep Periprosthetic Hip Joint Infection

How Should Antibiotics Be Used in Primary and Revision Hip and Knee Arthroplasty? An Introduction

Joint arthroplasty is a highly successful surgical treatment for symptomatic arthritis of the hip and knee. Despite excellent pain relief and prosthesis survival of approximately 90% at 20 years, complications occur [[1]Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)Hip, Knee & Shoulder Arthroplasty: 2021 Annual Report. AOA, Adelaide2021: 1-432https://aoanjrr.sahmri.com/annual-reports-2021Google Scholar]. Deep periprosthetic joint infection (PJI) is among the top 2 causes of failure around the world after primary and revision, hip and knee replacement at both short-term and long-term follow-up [1Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)Hip, Knee & Shoulder Arthroplasty: 2021 Annual Report. AOA, Adelaide2021: 1-432https://aoanjrr.sahmri.com/annual-reports-2021Google Scholar, 2Meyer J.A. Zhu M. Cavadino A. Coleman B. Munro J.T. Young S.W. Infection and periprosthetic fracture are the leading causes of failure after aseptic revision total knee arthroplasty.Arch Orthop Trauma Surg. 2021; 141: 1373-1383Crossref PubMed Scopus (9) Google Scholar, 3Le D.H. Goodman S.B. Maloney W.J. Huddleston J.I. Current modes of failure in TKA: infection, instability, and stiffness predominate.Clin Orthop Relat Res. 2014; 472: 2197-2200Crossref PubMed Scopus (183) Google Scholar]. In distinction to many other problems, such as dislocation and polyethylene wear that can be directly influenced by improvements in surgical technique and prosthesis design, surgeons may find it more frustrating to reduce surgical site infections. It is important to remember that appropriate use of prophylactic antibiotics, introduced over 50 years ago, remains the single most effective intervention available [[4]Burke J.F. The effective period of preventive antibiotic action in experimental incisions and dermal lesions.Surgery. 1961; 50: 161-168PubMed Google Scholar]. In our well-intentioned pursuit of completely eliminating PJI we can sometimes fall victim to the more is better philosophy. Indeed, over the past few years we have seen the introduction of new delivery methods, dosing schedules, and adjunctive products that encourage us to expand our use of prophylactic antibiotics without conclusive evidence. Additionally, our own success has led us to implement change before results from level 1A studies are available. Although PJI remains a persistent concern, the absolute rate of PJI after hip and knee arthroplasty remains low. Consequently, proving the value of new interventions remains problematic due to the large number of patients and extended follow-up duration required for definitive studies [[5]Thompson K.M. Oldenburg W.A. Deschamps C. Rupp W.C. MD Smith C.D. Chasing zero: the drive to eliminate surgical site infections.Ann Surg. 2011; 254: 430-436Crossref PubMed Scopus (65) Google Scholar]. Furthermore, the distinctions among prophylactic, treatment, and suppressive use of antibiotics have become blurred at times. It is important to remember that overuse of antibiotics has potentially significant consequences including the emergence of antibiotic resistance at the individual and societal levels, and individual patient side effects that can have serious consequences, such as acute kidney injury and allergic reaction [[6]Kheir M.M. Dilley J.E. Ziemba-Davis M. Meneghini R.M. The AAHKS clinical research award: extended oral antibiotics prevent periprosthetic joint infection in high-risk cases: 3855 patients with 1-Year follow-up.J Arthroplasty. 2021; 36: S18-S25Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar]. In this series of papers, drawn from presentations from the AAHKS Annual Meeting Symposium: Antibiotic Use in Primary and Revision Total Hip and Knee Arthroplasty, we will discuss the most effective uses of antibiotics before, during, and after surgery in order to reduce deep PJI. Each paper, authored by an expert in the field, will summarize the published data and clinical guidelines pertinent to the topic and distill the information to pragmatic advice that is ready for use in your practice. Download .docx (.02 MB) Help with docx files Conflict of Interest Statement for Clarke

Frailty Transitions One Year After Total Joint Arthroplasty: A Cohort Study.

Total joint arthroplasty (TJA) is prevalent and offered to patients regardless of frailty status experiencing pain, disability, and functional decline. This study aims to describe changes in levels of frailty 1 year after TJA. We identified a retrospective cohort of adult patients undergoing primary TJA between 2005 and 2016 using an institutional total joint registry. Associations between categorized frailty deficit index (FI) and change in FI were analyzed using linear regression models. Mortality, deep periprosthetic joint infection, and reoperation were analyzed using time to event methods. In total, 5341 patients (37.6% non-frail, 39.4% vulnerable, and 23.0% frail) with items necessary to determine FI at 1 year after TJA were included. Preoperatively, 29% of vulnerable patients improved to non-frail 1 year later, compared to only 11% regressing to frail. Four in 10 frail patients improved to vulnerable/non-frail. Improvements in activities of daily living (ADL) were more evident in frail and vulnerable patients, with >30% reduction in the percentage of patients expressing difficulties with walking, climbing stairs, and requiring ADL assistance 1 year after TJA. Increases in frailty 1 year after TJA were associated with significantly increased rates of mortality (hazard ratio [HR] 1.50, 95% confidence interval [CI] 1.24-1.82, P < .001), deep periprosthetic joint infection (HR 3.98, 95% CI 1.85-8.58, P < .001), and reoperation (HR 1.80, 95% CI 1.19-2.72, P= .005). Frailty states are dynamic with patient frailty shown to be modifiable 1 year after TJA. Preoperative frailty measurement is an important step toward identifying those that may benefit most from TJA and for postoperative frailty surveillance.

Periprosthetic joint infections: a 20 years retrospective epidemiological study in a single european accademic hospital

Introduction: Periprosthetic Joint infections (PJIs) still represent one of the most challenging complications in orthopaedic reconstructive surgery. The aim of our work is to present a retrospective observational analysis with 20 years of follow up of PJIs referred to a single center equipped with a regional referral infectious diseases department. Materials and methods: 368 case of deep PJIs following a primary or revision hip and knee arthroplasty procedure referred to our center between January 1996 and December 2016 were included in the study. Criteria of inclusion in the study was a primary PJI entirely managed in our hospital. We collected demographic data, risk factors, microbiology (identification pathogenic agent), previous surgical treatments, type of implant, diagnostic criteria of infection, type of infection and medical or surgical treatments performed in our institution Results: A total of 200 (54,3%) infection occurs in hip arthroplasty and 168 (45,7%) in knee arthroplasty. Mean age was 64,7 years. The majority were late infections (58,8%). Respectively polymicrobial infections was identified in 83 (22,6%) cases and in 54 (14,7%) patients no isolation was possible. S. Aureus was the most frequently identified pathogen. The major risk factors were hypertension in 254 (69,1%), cardiovascular diseases in 167 (45,7%), obesity in 97 (26,5%) and diabetes mellitus in 92 (25%). Discussion: Epidemiological analysis of PJI in our hospital which collects data relating to the last 20 years, has permitted to obtain a summary of our scenario. Ideal PJI management should include an accurate patient history considering carefully risk factors, patients conditions, and previous surgical procedures ideally in a multispecialist enviroment.

Two-stage reimplantation for deep infection after total elbow arthroplasty.

Persistent infection rate after 2-stage reimplantation complicating elbow arthroplasty has been reported to be as high as 25%. The purposes of this retrospective study were to determine the infection eradication rates, complications and outcomes in a cohort of patients treated with two-stage reimplantation for deep periprosthetic joint infection (PJI) following total elbow arthroplasty (TEA) and to determine possible associated risk factors for treatment failure. Between 2000 and 2017, 52 elbows underwent a two-stage reimplantation for PJI after TEA. There were 22 males and 30 females with a mean age of 61 (range, 25-82) years. The most common bacterium was Staphylococcus epidermidis (28 elbows). Mayo Elbow Performance Scores were calculated at the latest follow-up. Mean follow-up time was 6 years (range, 2-14 years). PJI was eradicated in 36 elbows (69%). The remaining 16 elbows were considered treatment failures secondary to recurrent infection. The risk of persistent infection was 3.3 times higher in elbows with retained cement (p 0.04), and 3.5 times higher when the infecting organism was Staphylococcus epidermidis (p 0.06). Two-stage reimplantation for PJI after TEA was successful in eradicating deep infection in 69% of cases. The eradication of PJI after TEA still needs to be improved substantially.

Выбор спейсера на первом этапе лечения поздней глубокой перипротезной инфекции тазобедренного сустава

Abstract. Introduction Periprosthetic infection in hip arthroplasty is a social and economic problem. Its main reason is multidrug resistance of microorganisms. Purpose To evaluate the effectiveness of the first stage in two-stage revision arthroplasty for the treatment of deep periprosthetic infection of the hip joint by improving the constructive and antibacterial features of spacers. Materials and methods The treatment results of 127 patients with late deep periprosthetic hip joint infection who underwent two-stage revision arthroplasty in the period from 2015 to 2019 were analyzed. In the first group, 42 patients were fitted with a two-component (total) spacer based on the developed antimicrobial composition of bone cement with gentamicin, antiseptics and polymer (patent RU 191236). In the second group, a two-component spacer (patent RU 174697) based on conventional bone cement with gentamicin was implanted in 43 patients; the third group of 42 patients had a preformed spacer. Results A bactericidal and antiadhesive, nontoxic composition based on bone cement with gentamicin with antiseptics poviargol, dioxidine and high molecular weight polyvinylpyrrolidone with a prolonged action for 348 days against gentamicin-resistant staphylococci has been developed. All patients underwent the first stage of hip arthroplasty with removal of the implant and installation of a spacer. Recurrence of periprosthetic infection was observed in 1 (2.3 %) patient of the first group, in 5 (11.6 %) in the second and in 6 (14.2 %) patients of the third group. Non-infectious complications such as spacer dislocation and instability were observed in 12 cases, one case (2.3 %) in the first, 2 (4.6 %) in the second and 9 (21.4 %) in the third group. The average time from the first stage of treatment to the second stage of re-implantation was 7.5 months (range, 4–13 months). Discussion According to the literature, the introduction of new antibiotics into the bone cement with gentamicin does not increase the antimicrobial action of the spacer, especially against antibiotic-resistant isolates, and the use of a preformed spacer contributes to an increase in the number of non-infectious complications. Antiseptics with different mechanisms of action are able to act on antibiotic-resistant bacteria, and the polymer can prolong this effect. Conclusions Creation of two-component spacers based on bone cement with gentamicin using antiseptics with different mechanisms of action and polymer promotes long-term bactericidal action of the spacer, which leads to effective sanation of the joint area, reducing non-infectious complications.

Treatment of deep periprosthetic hip infection with articulating cement-antibiotic spacers with silver plates and antibiotics

The aim of this work is to improve the results of treatment of patients with a deep periprosthetic hip joint infection by using an articulating cement-antibiotic spacer in combination with silver plates and antibiotics.Material and methods. The treatment outcomes of 52 patients operated at the Swedish-Ukrainian Angelholm Medical Center for the period from 2017 to 2020, who underwent two-stage revision arthroplasty for the deep periprosthetic infectious-inflammatory process of the hip joint, were studied. In addition, 9 patients were examined in whom, during the first stage of a two-stage treatment of an artificial hip joint infection, an articulating cement-antibiotic spacer made of bone cement with a silver content was developed.Research results. Long-term results of two-stage revision arthroplasty with the introduction of our proposed cement-antibiotic spacers were studied in 49 (94.2%) patients. Among them, 9 patients used silver plates, which showed good patient tolerance and in all cases the infection was overcome. In 49 patients in whom the long-term results of two-stage revision hip arthroplasty were studied, 44 (89.8%) achieved eradication of the infection with restoration of the function of the operated limb. We rated such results as good. The average HHS score in this group was 87.18 ± 6.44 points.Conclusions. An innovative method of treatment of deep periprosthetic infection of the hip joint has been introduced into clinical practice, which consists in increasing the effectiveness of using an articulating cement antibiotic spacer by adding silver plates to it and, in addition, an antibiotic.

Review of complications, functional outcome, and long-term survival following conversion of hip fusion to total hip arthroplasty.

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants. A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed. At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint. The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J2021;103-B(7 Supple B):129-134.

The Utility of MRI With Multiacquisition Variable-Resonance Image Combination (MAVRIC) in Diagnosing Deep Total Hip Arthroplasty Infection.

Background: The 2010 American Academy of Orthopaedic Surgeons Clinical Practice Guidelines report insufficient evidence to address the diagnostic efficacy of magnetic resonance imaging (MRI) for periprosthetic joint infection (PJI). Questions/Purposes: The purpose of this study was to determine the utility of MRI with multiacquisition variable-resonance image combination (MAVRIC) metal artifact suppression techniques in diagnosing PJI in the setting of total hip arthroplasty (THA). Methods: Multiacquisition variable-resonance image combination MRIs obtained of THAs between November 2012 and November 2016 were queried. Radiology reports were classified as positive (suspicious for infection), negative (no features of infection), or inconclusive (infection cannot be excluded or correlation with aspiration suggested if clinically concerned). Chart review identified cases of deep PJI according to the modified Musculoskeletal Infection Society criteria. Results: Of 2156 MRIs of THAs included, MRI was concerning for infection in 1.8% (n = 39), inconclusive in 1.2% (n = 26), and negative in 97.0% (n = 2091). Deep PJI was identified in 53 (2.5%) patients, 30 of whom (56.6%) had conclusively positive finding on MRI (false-negative rate: 43.4%, sensitivity: 56.6%). Of 2103 aseptic THAs, only 9 (0.4%) MRIs were read as suspicious for infection (false-positive rate: 0.4%; specificity: 99.6%). Conclusion: Magnetic resonance imaging with MAVRIC is a highly specific test for PJI with a low false-positive rate. This indicates that when clinicians are provided with an MRI that unexpectedly suggests infection, a formal evaluation for infection is indicated. In patients with otherwise equivocal diagnostic findings, MRI may help confirm, but not refute, a diagnosis of PJI. Prospective study with more experienced image reviewers may further support the use of MRI in PJI.

Does the Organism Profile of Periprosthetic Joint Infections Change With a Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Protocol?

BackgroundWhile vancomycin powder and dilute povidone-iodine (VIP) is associated with fewer total joint arthroplasty (TJA) periprosthetic joint infections (PJI), its effect on PJI organism profiles is unclear. This study evaluates primary TJA PJI organism profiles before and after the implementation of a VIP protocol. MethodsIn total, 18,299 primary TJAs performed at a university-affiliated, not-for-profit orthopedic hospital from before (1/2012-12/2013) and after (1/2016-12/2019) a VIP protocol was initiated were reviewed to identify deep PJIs that occurred within 90 days of the index arthroplasty as defined by the Musculoskeletal Infection Society guidelines. Demographics, overall organism incidence (n/TJAs), and relative organism incidence (n/PJIs) from the two cohorts were compared. ResultsIn total, 103 TJA PJIs were identified (pre-VIP: 32/3982; VIP: 71/14,317). Following the introduction of VIP, the overall and relative incidence of coagulase-negative staphylococcal TJA PJIs significantly decreased (overall: 0.20% to 0.04%, P = .004; relative: 25.00% to 8.45%, P = .031). In response, the relative incidence of MSSA TJA PJIs significantly increased (18.75% to 40.85%, P = .042). Broken down by arthroplasty type, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal total knee arthroplasty (TKA) PJIs (0.27% to 0.06%, P = .015), a significantly lower overall incidence of MRSA TKA PJIs (0.18% to 0.03%, P = .031), and a nonsignificant decrease in the overall incidence of gram-negative TKA PJIs (0.18% to 0.04%, P = .059). No organism profile changes were found in total hip arthroplasty PJIs. ConclusionVIP is not associated with more difficult to treat primary TJA PJIs. While promising, these findings require a prospective randomized controlled trial for confirmation. Level of EvidenceLevel III, Retrospective cohort study;

Effects of Ciprofloxacin on the Dynamics of Biofilm Formation by Staphylococcus Epidermidis Strains Isolated from Implant-Associated Infection

Introduction. The formation of a microbial biofilm in implant-associated infection after arthroplasty of large joints reduces the informative value of traditional microbiological diagnostic methods and limits the range of effective antimicrobial drugs. When prescribing etiotropic therapy for periprosthetic joint infection, it is necessary to take into account not only the antibacterial effect of the drug, but also its effect on biofilm formation. Ciprofloxacin therapy may be a risk factor for the development of biofilm periprosthetic infection caused by multidrug-resistant staphylococcal strains.The aim of research was to study the effect of sub-inhibiting and therapeutic doses of ciprofloxacin on biofilm formation by Staphylococcus epidermidis strains isolated from implant-associated infection.Materials and methods. The authors studied the effect of various concentrations of ciprofloxacin on 15 strains of St. epidermidis isolated from 83 patients with deep periprosthetic joint infection after primary knee arthroplasty, treated at NIITON SSMU in 2018-2019. The effect of the calculated concentrations of ciprofloxacin on the planktonic culture, forming and preformed biofilms was investigated. Biofilm simulation was performed according to the method described by G.D. Christensen under in vitro conditions with determination of the optical density of alcohol eluates of gentian violet in polystyrene microplates.Results. It was demonstrated that ciprofloxacin in a dose 0.01 g/ml inhibits the growth of planktonic forms by 50% and statistically significantly (p = 0.001) stimulates formation of microbial biofilms as compared to the control without antibiotic addition. Concentration of ciprofloxacin equal 0.03 g/ml inhibits the growth of planktonic forms by 90%, statistically significantly (p = 0.001) stimulates formation of biofilms and activates further increase in the mass of pre-formed microbial biofilms. An increase in the concentration of ciprofloxacin to 0.05 g/ml completely inhibits the growth of planktonic forms and statistically significantly stimulates further growth of preformed biofilms.The use of ciprofloxacin at concentrations equal 1-3 g/ml statistically significantly (p = 0.001) inhibits the formation of microbial biofilms, but does not affect the preformed biofilm.Conclusions. Thus, there has been found a dose-dependent effect of ciprofloxacin towards clinical strains of St. epidermidis: subinhibitory and therapeutic concentrations of the drug have a stimulating effect on the formation and further increase in the mass of the preformed microbial biofilms. This fact must be taken into account when prescribing etiotropic therapy for implant-associated complications following large joint replacements.

Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients

BackgroundIntra-articular hyaluronic acid (IAHA) can be injected into an osteoarthritic hip joint to reduce pain and to improve functionality. Several studies report IAHA to be safe, with minor adverse effects that normally disappear spontaneously within a week. However, intra-articular corticosteroids prior to total hip arthroplasty (THA) have been associated with increased infection rates. This association has never been investigated for IAHA and THA. We aimed to assess the influence of IAHA on the outcome of THA, with an emphasis on periprosthetic joint infection (PJI). MethodsAt a mean follow-up of 52 months (±18), we compared complication rates, including superficial and deep PJIs, of THA in patients who received an IAHA injection ≤6 months prior to surgery (injection group) with that of patients undergoing THA without any previous injection in the ipsilateral hip (control group). One hundred thirteen patients (118 hips) could be retrospectively included in the injection group, and 452 patients (495 hips) in the control group. ResultsNo differences in baseline characteristics nor risk factors for PJI between the 2 groups were found. The clinical outcomes in terms of VAS pain scores (1.4 vs 1.7 points, P = .11), modified Harris Hip Scores (77 vs 75 points, P = .09), and Hip disability and Osteoarthritis Outcome Scores (79 vs 76 points, P = .24) did not differ between the injection group and the control group. Also, complications in terms of persistent wound leakage (0% vs 1.2%, P = .60), thromboembolic events (0% vs 0.6%, P = 1.00), periprosthetic fractures (1.7% vs 1.2%, P = .65), and dislocations (0% vs 0.4%, P = 1.00) did not differ. However, in the injection group there was a higher rate of PJIs (4% vs 0%, P < .001) and postoperative wound infections (9% vs 3%, P = .01), compared to the control group. ConclusionOur findings suggest that IAHA performed 6 months or less prior to THA may pose a risk for increased rates of PJI. We recommend refraining from performing THA within 6 months after IAHA administration.

Impact of Perioperative Urinary Tract Infection on Surgical Site Infection in Patients Undergoing Primary Hip and Knee Arthroplasty

BackgroundThe literature lacks clear consensus regarding the association between postoperative urinary tract infection (UTI) and surgical site infection (SSI). Additionally, in contrast to preoperative asymptomatic bacteriuria, SSI risk in patients with preoperative UTI has been incompletely studied. Therefore, our goal was to determine the effect of perioperative UTI on SSI in patients undergoing primary hip and knee arthroplasty. MethodsUsing the National Surgical Quality Improvement Program database, all patients undergoing primary hip and knee arthroplasty were identified. Univariate and multivariate regressions, as well as propensity matching, were used to determine the independent risk of preoperative and postoperative UTI on SSI, reported as odds ratios (ORs) with 95% confidence intervals (CIs). ResultsPostoperative UTI significantly increased the risk for superficial wound infection (OR 2.147, 95% CI 1.622-2.842), deep periprosthetic joint infection (PJI) (OR 2.288, 95% CI 1.579-3.316), and all SSIs (superficial and deep) (OR 2.193, 95% CI 1.741-2.763) (all P < .001). Preoperative UTI was not associated with a significantly increased risk of superficial infection (P = .636), PJI (P = .330), or all SSIs (P = .284). Further analysis of UTI present at the time of surgery using propensity matching showed no increased risk of superficial infection (P = 1.000), PJI (P = .624), or SSI (P = .546). ConclusionPostoperative UTI was associated with SSI, reinforcing the need to minimize factors which predispose patients to the risk of UTI after surgery. The lack of association between preoperative UTI and SSI suggests that hip and knee arthroplasty can proceed without delay, although initiating antibiotic treatment is prudent and future prospective investigations are warranted.

Clinical and microbiological characteristics of periprosthetic hip and knee infections

Objective. To characterize periprosthetic joint infection in patients undergoing a total hip and knee joint replacement. Materials and Methods. A total of 77 patients with periprosthetic infection following hip and knee joint replacement hospitalized in Grodno City Clinical Hospital were studied over the period of 2014-2018. Wound discharge, tissue samples, and fistula’s wall swab were used for microbiological tests. The analysis of surgical treatment of patients with deep periprosthetic knee and hip joint infection has been performed. Results. Periprosthetic infection after hip joint arthroplasty was observed in 32 (41.6%) patients, and after total knee joint arthroplasty in 45 (58.4%) patients. Surgical treatment was performed in 18 (56.3%) and 32 (71.1%) patients with periprosthetic infection following total knee and hip joint replacement, respectively. A total of 10 (31.2%) of 32 cultures from patients with periprosthetic infection after total hip joint replacement and 8 (17.8%) of 45 cultures from patients with periprosthetic infection after total knee joint replacement were positive. Overall, Staphylococcus aureus was detected in 9 (50%) of 18 positive cultures. Gram-negative aerobic bacteria (Acinetobacter baumannii, Klebsiella pneumoniae Pseudomonas aeruginosa) were detected in 4⁄10 and 5⁄8 of positive cultures from patients with periprosthetic infection of hip and knee joints, respectively. Conclusions. The most common pathogens causing periprosthetic infection of hip and knee joints were S. aureus (50%) and Gram-negative bacteria. The surgical treatment was performed in 71.4% of patients with periprosthetic joint infection.

Early Deep Periprosthetic Hip Infection of Odontogenic Origin (Case Report)

Deep periprosthetic joint infection (PJI) is a severe complication after primary and revision hip joint arthroplasty resulting in multiple interventions on the joint. The present paper describes a rare case of early deep hip PJI of odontogenic etiology. The patient suffered from early PJI after a planned procedure of left hip joint arthroplasty. Antibacterial therapy without surgical debridement was performed in an outpatient unit which resulted in a late, on day 12th after surgery, admittance of the patient to hospital with continued administration of antibiotics. Treatment tactics was selected upon patient’s admission basing on patient complaints, medical history of the disease, clinical signs and findings of roentgenological, laboratory and bacteriological examinations. Two-stage treatment consisting of revision, removal of implant, debridement, biopsy and wound drainage by a swab was performed and followed by empiric antibacterial therapy (for 5 days). Targeted antibacterial therapy was prescribed basing on bacteriological test findings. Together with dentists the authors examined oral cavity of the patient, identified a site of chronic infection and undertook the focused treatment by dental extraction and sanitation of the oral cavity. Postoperative period after the first stage was uncomplicated. Second stage of revision (re-arthroplasty of left hip joint) was performed on week 36 of the surgical time-out with a good clinical outcome: 80 points on Harris hip score in 40 weeks after the second stage. Presented clinical case illustrates the existence of hematogenous mechanism of postoperative microorganism dissemination from the chronic infection nidus with subsequent progression of inflammation at the surgical site, including PJI. In the present case the Actinomyces odontolyticus was isolated from periprosthetic tissues and parodontal recesses which allowed the authors to suggest a highly probable cause for early PJI by Actinomyces odontolyticus translocation into periprosthetic tissues of the hip joint. However, strain sequencing is required for the complete verification. The described case confirms the need for debridement of chronic infection nidus prior to joint arthroplasty aiming at prevention of hematogenous periprosthetic infection.

Two-Stage Treatment of Periprostetic Infection: Mid-Term Results

Purpose — to evaluate the efficiency of two-stage revision arthroplasty performed according to a standardized protocol by a multidisciplinary surgical team. Materials and Methods. 87 patients with deep periprosthetic hip and knee joint infection (PJI) were included into the prospective study. The patients were admitted to the clinic in the period from January 2012 until December 2014 and underwent two-stage revision procedure. First stage included removal of infected implant and insertion of a cemented spacer, second stage — re-implantation of a prosthesis. Results. Re-implantation of a prosthesis was performed in 89.7% (95% CI 82.8–95.4) of cases. Infection recurrence rate was 13.8% (95% CI 6.9–20.7) and 12.8% (95% CI 6.4–21.8) after the first and the second stage, respectively. Overall efficiency of two-stage procedure was 80,5% (95% CI 71.3–88.5) with a median of 4.7 year follow up. Conclusion. Rate of re-implantation, recurrent infection and newly occurred infection should be taken into consideration for evaluation of treatment efficiency. Application of single criteria for assessment of successful treatment outcomes will allow to compare various studies. Positive microbiological tests during the second stage of procedure are not a risk factor for recurrent infection but can be caused by contamination of specimens.

Possible risk factors for acute and chronic deep periprosthetic joint infections in primary total knee arthroplasty. Do BMI, smoking, urinary tract infections, gender, and ASA classification have an impact?

PurposeAim of this retrospective study was to evaluate the impact of the patient related factors body mass index (BMI), urinary tract infection, current smoking, gender, and American Society of Anesthesiologists (ASA) classification on the incidence of acute and chronic deep periprosthetic joint infections (PJI) in total knee arthroplasty (TKA). MethodsAll patients undergoing revision surgery for a deep PJI of primary TKA between July 2012 and December 2016 were included in this study. All relevant data was collected from the medical records. Acute deep PJI was defined when PJI was diagnosed within the first 6 weeks after primary TKA, chronic PJI was defined when patients demonstrated PJI later than 6 weeks after primary TKA. ResultsA total of 57 patients was included in this study with 13 cases of acute PJI and 44 of chronic PJI. Overweight patients (BMI > 25 kg/m2) represent a significantly larger proportion in both PJI groups (p < 0.05). Current smokers had an significantly increased risk for acute and chronic PJI (p < 0.05). In the acute PJI group 46.2% patients had an postoperative urinary tract infection. ConclusionAn elevated BMI (>25 kg/m2), current smoking and urinary tract infection are possible risk factors for acute and chronic deep PJI. After primary TKA screening for urinary tract infection is recommendable to prevent predominantly acute deep PJI.