Infected Hip Research Articles

Cutibacterium acnes periprosthetic joint infections.

Cutibacterium acnes (C. acnes; previously known as Propionibacterium acnes or P. acnes) periprosthetic hip and knee infections are under-reported. While culture contamination with C. acnes occurs, true infections are important to recognize and treat. We sought to describe the demographics and treatment outcomes of patients with C. acnes periprosthetic joint infections (PJIs) of the hip and knee. Patients with C. acnes PJI between January 2005 and December 2018 were retrospectively reviewed utilizing the institutional total joint registry. Patients with monomicrobial PJI and two or more positive cultures were considered to have true C. acnes PJI. Patients with polymicrobial infection or with only one positive culture were excluded. This resulted in 35 PJIs (21 hips and 14 knees); the patients' mean age was 63 years (35 to 84) and 15 (43%) were female. Mean follow-up was five years (1 to 14). The median time to positive culture was five days (IQR 5 to 6) and median synovial fluid cell count was 22,583 cells (IQR 15,200 to 53,231). The median ESR was 25 mm/hr (IQR 7 to 37), and CRP was 15 mg/l (IQR 3 to 29). Of the 35 PJIs, 18 (51%) were treated with chronic antibiotic suppression without surgical intervention, and the remainder were treated with two-stage exchange arthroplasty. The two-year survival free of any revision was 94%. Four patients failed treatment due to symptomatic infection, with three treated with two-stage exchange and one treated with irrigation and debridement with modular component exchange for a survival rate of 89% and 83% at two and five years, respectively. Laboratory evidence of C. acnes PJI in this cohort was typical compared to more conventional organisms. Cultures grew more quickly than previously thought in patients with C. acnes PJI. Treatment with two-stage exchange or chronic antibiotic suppression alone both had few treatment failures at mid-term follow-up.

A prospective cost analysis model for financial impact of Connected Care interventions on hospitals’ budget

ObjectivesTo present a prospective cost analysis (PCA) model for estimating the financial impact of Connected Care interventions in hospitals to support managerial decision-making, and describe its application to three different care pathways. MethodsInput of the developed PCA model consisted of standard of care input and intervention-specific input. The output of the model included: capacity benefits, costs, and reimbursements. The model was applied to three types of interventions in a large Dutch teaching hospital: 1) home telemonitoring for chronic patients (case (COPD), 2) remote aftercare for patients with acute illnesses (case: stroke), and 3) parenteral medication administration at home (case: prosthetic hip or knee joint infections). ResultsOutput of the PCA model showed that the cost savings can exceed the intervention costs if an intervention decreases the length of stay of patients. For COPD telemonitoring 10.1 % of the healthcare utilization should be reduced to reach break-even, and for antibiotic treatment at home break-even is reached if 4.6 % of the length of stay is reduced. The cost savings of remote aftercare for stroke patients is focused on reducing outpatient visits, and in the current Dutch reimbursement system this does not completely cover the costs. ConclusionsThe PCA model is an easy to implement and useful tool for assessing the financial impact of CC interventions from a hospital perspective. It supports decision makers to prospectively assess the cost and capacity benefits of interventions and to inform decisions on implementation. Further studies are needed to extend the model across the entire healthcare continuum. Public interest summaryWe present a prospective cost analysis (PCA) model for estimating the financial impact of Connected Care interventions in hospitals to support managerial decision-making. Connected Care interventions are based on an integrated care approach utilizing digital health technologies to enhance patient-centred, collaborative care, where patients receive care at home. Examples are telemonitoring of chronic obstructive pulmonary disease (COPD) patients, remote aftercare for stroke patients and infusion treatment at home for orthopaedic patients with an infection. These interventions have additional costs, but also save part of the costs of the conventional care, and have benefits in terms of a decrease in outpatient visits or hospitalizations. We provide a model where a hospital can calculate the impact in costs and benefits of Connected Care interventions and test this on these three examples. We show that the cost savings are able to exceed the intervention costs if an intervention has impact on the hospitalization.

Outcomes, Complications, and Eradication Rates of Two-Stage Revision Surgery for Periprosthetic Shoulder, Elbow, Hip, and Knee Infections: A Systematic Review

Outcomes, Complications, and Eradication Rates of Two-Stage Revision Surgery for Periprosthetic Shoulder, Elbow, Hip, and Knee Infections: A Systematic Review

Estimation of two-year hospital costs of hip and knee periprosthetic joint infection treatments using activity-based costing.

Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months. Using admission and procedure data from a prospective observational cohort in Australia and New Zealand, Australian Refined Diagnosis Related Groups were assigned to each admitted patient episode of care for activity-based costing estimates of 273 hip PJI patients and 377 knee PJI patients. Costs were aggregated at 24 months post-diagnosis, and are presented in Australian dollars. The mean cost per hip and knee PJI patient was $64,585 (SD $53,550). Single-stage revision mean costs were $67,029 (SD $47,116) and $80,063 (SD $42,438) for hip and knee, respectively. Two-stage revision costs were $113,226 (SD $66,724) and $122,425 (SD $60,874) for hip and knee, respectively. Debridement, antibiotics, and implant retention in hips and knees mean costs were $53,537 (SD$ 39,342) and $48,463 (SD $33,179), respectively. Suppressive antibiotic therapy without surgical management mean costs were $20,296 (SD $8,875) for hip patients and $16,481 (SD $6,712) for knee patients. Hip patients had 16 different treatment pathways and knee patients had 18 treatment pathways. Additional treatment, episodes of care, and length of stay contributed to substantially increased costs up to a maximum of $369,948. Treating PJI incurs a substantial cost burden, which is substantially influenced by management strategy. With an annual PJI incidence of 3,900, the cost burden would be in excess of $250 million to the Australian healthcare system. Treatment pathways with additional surgery, more episodes of care, and a longer length of stay substantially increase the associated hospital costs. Prospectively monitoring individual patient treatment pathways beyond initial management is important when quantifying PJI treatment cost. Our study highlights the importance of optimizing initial surgical treatment, and informs treating hospitals of the resources required to provide care for PJI patients.

“Implant-associated infection after hip fracture surgery in elderly patients: Risk factors and mortality”

AimsOur study aimed to evaluate the prognosis of implant-related infection following hip fracture and pre-surgical, surgical and microbiological factors modifying outcomes. MethodsWe retrospectively included patients aged 65 and older treated for infection following surgically managed hip fractures between 2012 and 2022. Periprosthetic and high-energy fractures were excluded. Data was obtained by clinical chart review, including: age, gender, Barthel index, Charlson Score, National Hip Fracture Database (NHFD) Mobility Score, surgery and infection type, causative pathogens, antimicrobial resistance, anti-biofilm antibiotic treatment and clinical situation at one-year follow up. The outcomes evaluated were failure/resolution of infection and one-year mortality. ResultsWe included 80 patients (67 women, 83.8 %) aged a median of 85 years (interquartile range: 78 – 88 years). Treatment failed in 38 (47.5 %) patients, and the one-year mortality was 37.5 %. Patients dying within 12 months after treatment were more likely to suffer acute vs. chronic infections (OR = 3.29 [95 %CI: 1.20–9.04]), be older and have more comorbidity, but baseline function and ambulation were not predictive. Treatment failure was higher among patients receiving non-antibiofilm controlling surgery, specifically surgical lavage (OR = 3.79 [95 %CI: 1.38–10,37]), as well as in older, more dependent patients. Receiving anti-biofilm antibiotics for more than 2 weeks was associated with less treatment failure (OR:0.32; [95 %CI: 0.13–0.80]) and 12-month mortality (OR:0.22 [95 %CI: 0.08–0.60]). ConclusionsAntibiofilm-controlling surgery and antibiotics improve treatment success following implant-related infection after hip fracture and should be considered regardless of fracture type. Acute infections are a “second hit” for frail patients recovering from initial surgery and are associated with increased mortality.

Post-operative short-term clinical evaluation of direct lateral (Harding) approach in primary total hip replacement.

To evaluate patients' functional outcomes after total hip arthroplasty through a direct lateral approach. The prospective, observational, descriptive study was conducted at Al-Yarmouk Teaching Hospital, Baghdad, Iraq, from May 2019 to June 2020, and comprised patients aged 28-81 years having advanced osteoarthritis and avascular necrosis who underwent cementless total hip arthroplasty. The patients were followed up for 6 months. Outcome was assessed using the Harris hip score, Trendelenburg sign, post-operative hip dislocation, post-operative infection, and heterotopic ossifications. Data was analysed using Excel version 2019. Of the 30 patients, 14(47%) were males and 16(53%) were females. The overall mean age was 49.8±15.28 years. The mean pre-operative Harris hip score was 43.166±8.27, while it was 83.566±3.83 post-operatively (p<0.001). There was 1(3.33%) case of heterotopic ossification, 3(10%) had Trendelenburg sign. There was no case of postoperative hip dislocation or infection. The lateral hip approach was found to be associated with good post-operative hip stability and good post-operative functional outcome with low post-operative risk of infection.

Modular component exchange has no advantage in Debridement, Antibiotics and Implant Retention (DAIR) for early onset hip and knee prosthetic joint infection.

Debridement, Antibiotics and Implant Retention (DAIR) has been the mainstay of treatment for early onset periprosthetic joint infection in spite of variable results. Modular component exchange is a widely recommended strategy to improve success rates with DAIR though very strong evidence to support its practice is still lacking. Eighty six patients underwent DAIR for early onset PJI following primary hip and knee arthroplasty were divided into two groups for this retrospective review. 45 patients (group 1) underwent DAIR with modular component exchange and 41 patients without exchange (group 2). We compared success rates based on infection eradication (primary outcome variable) and need for revision surgical procedures between these two groups. We also assessed differences in primary outcome based on type of arthroplasty, timing of DAIR and addition of local antibiotics. The overall success rate after DAIR was 71%. The outcome was similar in both groups (69% vs 74%, P = 0.66). The need for revision surgical procedures was 27% which was similar in both groups (P = 0.98) with 23% needing revision of prosthetic components. Type of arthroplasty (hip or knee) and addition of local antibiotics had no bearing on infection eradication after DAIR with or without modular component exchange. DAIR with in 45days of primary arthroplasty had significantly higher success rate compared to DAIR after 45days in both groups. We observed that modular component exchange did not improve infection eradication after DAIR for early onset PJI following hip and knee arthroplasty. Reasonable success rates can be expected after DAIR especially if the patient develops early clinical signs and the procedure is carried out as early as possible.

Modern cementless acetabular cups in total hip arthroplasty performed for primary osteoarthritis: a comparative registry study.

Comparative studies evaluating the different material and surface finishing of acetabular components in total hip arthroplasty (THA) are lacking. Using a regional arthroplasty registry, the survival rates and the hazard ratios of different cups in THA performed for primary osteoarthritis were assessed, using endpoints: (1) every cup failure, (2) cup aseptic loosening, (3) periprosthetic infection. The inclusion criteria were: residing patients, THA for primary osteoarthritis, Delta-on-Delta bearings, head sizes 32mm and 36mm. Only the most implanted cementless cups were considered and were grouped according to material and surface finishing into three cohorts: 3D printed cups (I), ultraporous tantalum or titanium- coated cups (II), second-generation cups (III). 15,737 cups were included in the study: 9,862 cups (62.7%) in cohort I, 2,067 implants (13.1%) in cohort II, 3,808 implants (24.2%) in cohort III. The three cohorts achieved comparable general 10-year survival rates (p = 0.62). In I and II cohorts, the survival rates of the cup types within cohorts were analogous (p = 0.86 and p = 0.31), but not in cohort III (p = 0.004). The hazard ratios for overall failure adjusted for age and sex were similar among the cohorts. Regarding cup aseptic loosening, the three cohorts had similar rates (p = 0.48) and similar adjusted hazard ratios. With periprosthetic hip infection as endpoint, the survival rates and the adjusted hazard ratios of the three cohorts were comparable (p = 0.68). 3D printed cups provided similar 10-year outcomes compared to ultraporous cups and second-generation cups, with no additional risks of aseptic loosening and infection. IV (therapeutic study). - 3D printed cups provided similar 10-year outcomes compared to ultraporous cups and second-generation cups. - There is no additional risks of aseptic loosening and infection.

The long-term time course of septic arthritis.

The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by Staphylococcus aureus would be more likely to have adverse outcomes than those infected by other organisms. All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome. A total of 142 patients were confirmed to have had an episode of septic arthritis in a native hip (n = 17) or knee joint (n = 125). S. aureus accounted for 57.7% of all hip and knee joint infections. There were 13 inpatient deaths attributed to septic arthritis. The median age of the patients who died was 77.5 (46.9 to 92.2) and their median age-adjusted CCI was 8 (6 to 12). A failure of the joint occurred in 26 knees (21%) and nine hips (53%). Of the knee joints infected by S. aureus (n = 71), 23 knees (32%) went into failure of joint, whereas of those infected by other organisms (n = 54), only three knees (6%) failed. Based on our study findings, hip and knee septic arthritis long-term outcomes were substantially worse than their immediate outcome suggested. Failure of knee joint is 6.1 times more likely to occur in those infected with S. aureus.

One-Stage Versus Two-Stage Revision Surgery for Periprosthetic Hip Infection: An Updated Systematic Review and Meta-Analysis of Clinical Outcomes

Introduction: The primary objective of this meta-analysis was to evaluate and compare the functional outcomes, postoperative reinfection rates, and complication rates in patients undergoing one-stage versus two-stage surgical revision for periprosthetic hip infection. Methods: The study population included adult patients who had undergone revision hip arthroplasty. Comparative studies have compared two-stage and one-stage revision strategies. Searches were conducted using the major databases. Review Manager software was used to estimate the effects. A sensitivity analysis was also conducted. Results: Nine cohort studies including 2,502 hips were included. The success rate did not show significant differences between the groups (odds ratio [OR] 0.42, 95% confidence interval 0.05 to 3.37). No difference was noted in reinfection (OR 0.81, 95% CI 0.56-1.19). Life quality per Harris Hip Score was higher for one-stage revision strategies (mean difference [MD] 9.00, 95% CI 2.23-15.78). No differences were noted in mortality, aseptic loosening, or revision rates. Age (MD 2.32, 95% CI 1.34-3.29) and body mass index (BMI) (MD 1.88, 95% CI 0.38-3.38) were lower in the two-stage group. Sinus tract presence was higher in the one-stage group (OR 1.44, 95% CI 1.05-1.95). Paprosky I acetabulum was higher in the one-stage group, and Paprosky III was higher in the two-stage group. Conclusions: The results did not demonstrate notable clinical differences between one-stage and two-stage hip arthroplasties, regardless of the treated microorganism. However, the quality of life may be somewhat better in the one-stage group. Age, body mass index, and Paprosky classification are factors that influence procedure selection.

Intra and Inter-Rater Variability in the Interpretation of White Blood Cell Scintigraphy of Hip and Knee Prostheses.

Background: White blood cell (WBC) scintigraphy plays a major role in the diagnostic approach to periprosthetic infections. Although the procedure has been standardized by the publication of several guidelines, the interpretation of this technique may be susceptible to intra and inter-variability. We aimed to assess the reproducibility of interpretation between nuclear medicine physicians and by the same physician and to demonstrate that Cohen's coefficient is more unstable than Gwet's coefficient, as the latter is influenced by the prevalence rates. Methods: We enrolled 59 patients who performed a Technetium-99m WBC (99mTc-WBC) scintigraphy for suspected hip or knee prosthesis infection. Three physicians, blinded to all patient clinical data, performed two image readings. Each WBC study was assessed both visually and semi-quantitatively according to the guidelines of the European Association of Nuclear Medicine (EANM). For semi-quantitative analysis, readers drew an irregular Region of Interest (ROI) over the suspected infectious lesion and copied it to the normal contralateral bone. The mean counts per ROI were used to calculate lesion-to-reference tissue (LR) ratios for both late and delayed images. An increase in LR over time (LRlate> LRdelayed) of more than 20% was considered indicative of infection. Agreement between readers and between readings was assessed by the first-order agreement coefficient (Gwet's AC1). Reading time for each scan was compared between the three readers in both the first and the second reading, using the Generalized Linear Mixed Model. Results: An excellent agreement was found among all three readers: 0.90 for the first reading and 0.94 for the second reading. Both inter- and intra-variability showed values ≥0.86. Gwet's method demonstrated greater robustness than the Cohen coefficient when assessing the intra and inter-rater variability, since it is not influenced by the prevalence rate. Conclusions: These studies can contribute to improving the reliability of nuclear medicine imaging techniques and to evaluating the effectiveness of trainee preparation.

Can a 1.5-Stage Revision be an Effective Alternative for Chronic Periprosthetic Hip and Knee Infections? A Systematic Review and Meta‐Analysis

BackgroundA 1.5-stage revision could be an alternative to a 2-stage revision for treating hip and knee chronic periprosthetic infections, guaranteeing the maintenance of joint function and infection control and preventing infection-free patients from undergoing further surgery. Our systematic review aimed to answer several questions about the indication, the infection eradication rate, and the long-term functional outcome of 1.5-stage revisions used to treat chronic periprosthetic infections of the hip and knee. MethodsA systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including studies dealing with the use of 1.5-stage and two-stage surgery for chronic periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) or total hip arthroplasty (THA). The Coleman Methodology Score and the Methodological Index for Non-randomized Studies (MINORS) score were used to assess the quality of the studies. A meta-analysis was performed to evaluate the infection eradication rate using either the 1.5-stage revision or the two-stage technique. A total of 494 patients (111 hips and 385 knees) who underwent 1.5-stage with a mean age of 69 years (range, 61 to 82) were identified in the ten included studies. ResultsThe most common cause of reoperation was the conversion to the definitive prosthesis, followed by aseptic loosening. Infection control was reached in 84.6% of the 1.5-stage and 76.1% of the two-stage cohorts. The infection recurrence rate was higher in the two-stage cohort than the 1.5-stage group (21.8 versus 14.3%). ConclusionThe 1.5-stage technique represents a valid treatment option in selected patients who have chronic PJI who cannot undergo further surgeries, adding together the benefits of the one- and two-stage procedures. Furthermore, the 1.5-stage showed a better success rate in the infection resolution than the two-stage technique.

One-stage revision for reconstructing acetabular defects by trabecular metal acetabular revision system in periprosthetic joint infection

Objective: To investigates the clinical efficacy of the trabecular metal acetabular revision system (TMARS) in one-stage reconstruction of acetabular deficiencies associated with periprosthetic joint infection (PJI). Methods: This is a retrospective case series study,including the data of 59 patients with PJI underwent acetabular defect reconstruction by TMARS during one-stage revisions in the Department of Orthopaedics, the First Affiliated Hospital of Xinjiang Medical University from January 2013 to December 2021. There were 32 males and 27 females, aged (59.5±14.6) years (range: 26 to 84 years). Among them, 29 cases used tantalum cups, 13 cases used tantalum cups and tantalum reinforcing blocks, 9 cases used cup-cage, and 8 cases used multi-cup reconstruction techniques. The surgery procedure, Harris Hip score (HHS), recovery of the hip rotation center, implant survival rate, postoperative reinfection rate, and complications were recorded. Data were compared using the Wilcoxon rank-sum test. Results: All of the 59 patients underwent the operations successfully. Operation time was (188.9±48.4) minutes (range: 110 to 340 minutes), and intraoperative bleeding volume was (M(IQR)) 1 000(400)ml (range: 600 to 1 800 ml). After a postoperative follow-up of 5.1 (2.6) years (range: 2.0 to 10.5 years), the prosthesis survival rate was 94.9% (56/59). Recurrence of infection occurred in 3 cases (5.1%), aseptic loosening in 1case(1.7%), and hip dislocation in 4 cases (6.8%). At the last follow-up, HHS improved significantly(84 (12) vs. 44 (9), Z=-6.671, P<0.01), and the center of rotation of the hips were recovered in all cases. Conclusions: In one-stage revision surgeries aimed at reconstructing acetabular defects, utilizing the TMARS can provide stable initial fixation, restore a more natural center of rotation, significantly enhance early postoperative hip joint function, and reduce the likelihood of infection recurrence. This approach stands as a reliable choice for addressing acetabular defects during revision surgeries for infected hip joints.

Selection of placement position of support points for early and mid-term mechanical repair of femoral head necrosis

To investigate the clinical efficacy of the placement of the main mechanical support points in the early and middle stages of mechanical repair of femoral head necrosis in preventing collapse of the femoral head. A retrospective analysis was performed for 17 cases 22 hips of non-traumatic femoral head necrosis in the early and middle stages from June 2018 to June 2019, including 14 males 18 hips and 3 females 4 hips, aged 34 to 47 years old. Among them, 6 cases were hormonal, 8 were alcoholic and 3 were idiopathic. According to China-Japan Friendship Hospital(CJFH) classification, 9 hip were type L1, 8 were L2, 5 were L3. All cases were given dead bone scraping, autologous iliac granules pressed bone grafting, and allogeneic fibula column support treatment. After surgery, Sanqi Jiegu Pill() was administered orally for 3 months. X-rays of both hips were performed after surgery and follow-up, and the clinical efficacy was evaluated by hip Harris score before and after surgery. All cases were followed up for 24 to 38 months. The Harris score of 22 hips increased from 58 to 77 preoperative to 68 to 94 at the final follow-up. At the final follow-up, 3 hips were excellent, 11 hips were good, 3 hips were acceptable, 5 hips were poor. Two hips of L2 type progressed to ARCO ⅢB stage and continued to be observed, 2 hips of L2 type and 2 hips of L3 type progressed to ARCO Ⅳ stage, and received total hip replacement, and 1 hip infection at 3 months after surgery was given a cement spacer. Based on CJFH classification, collapse can be predicted to a certain extent according to the area, volume, location and human biological characteristics of osteonecrosis, and the main mechanical support points are found on this basis to prevent collapse.

LONG-TERM RESULTS OF 331 TWO-STAGE EXCHANGES FOR PERIPROSTHETIC JOINT INFECTION FOLLOWING TOTAL HIP ARTHROPLASTY: LOW REINFECTION AND MECHANICAL FAILURE RATES AT TEN YEARS

The relative advantages and disadvantages of two-stage versus one-stage management of infected total hip arthroplasties are the current subject of intense debate. To understand the merits of each approach detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of this study was to assess the long-term results of two-stage exchange arthroplasty for THAs in one of the largest series to date.We identified 331 infected THAs treated with a two-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had prior treatment for infection. Mean age at reimplantation was 66 years, 38% were female, and mean BMI was 30 kg/m2. PJI diagnosis was based on the 2011 MSIS criteria. A competing risk model accounting for death was utilized. Mean follow up was 8 years.The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI&gt;30 kg/m2 (HR 2; p=0.049), and need for a spacer exchange (HR 3.2; p=0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years; 45% required revision). Factors predictive of dislocation were female sex (HR 2; p=0.047) and BMI&lt;30 kg/m2 (HR 3; p=0.02). The mean HHS improved from 54 to 75 at 10 years.In this series of 331 two-stage exchange arthroplasties performed for infected hips, we found a low aseptic revision rate (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to one-stage exchanges.Level of Evidence: Level III

A COMPARATIVE ANALYSIS OF 1.5-STAGE AND TWO-STAGE REVISION FOR PERIPROSTHETIC JOINT INFECTION AFTER TOTAL HIP ARTHROPLASTY: IS 1.5-STAGE REALLY EQUIVALENT?

Two-stage exchange arthroplasty is traditionally used to treat periprosthetic hip infection. Nevertheless, particularly in high-risk patients, there has been increased attention towards alternatives such as 1.5-stage exchange arthroplasty which takes place in one surgery. Therefore, we sought to compare (1) operative time, length-of-stay (LOS), transfusions, (2) causative organism identification and polymicrobial infection rates, (3) re-revision rates and re-revision reasons, (4) mortality, and determine (5) independent predictors of re-revision.Retrospective chart review of 71 patients who underwent either 1.5- (n=38) or 2-stage (n=33) exchange hip arthroplasty at a single institution (03/2019-05/2023). Demographics, surgical, inpatient, and infection characteristics were noted. Main outcomes evaluated were re-revision rates, re-revision reasons, mortality, and cause of death. Independent predictors of re-revision were assessed utilizing logistic regression. Mean follow: 675 days (range, 23–1,715).Demographics were not significantly different except for a higher proportion of 1.5-stage patients classified as American-Society-of-Anesthesiologists (ASA) status 3 or 4 (84.2 vs. 48.5%, p=0.002). Length of follow-up was significantly longer in the 2-stage group (924.4 vs. 458 days, p&lt;0.001) as well as operative time (506 vs. 271 minutes, p&lt;0.001). In the 1.5-stage group, there was a higher proportion of polymicrobial infections (23.7 vs. 3.0%, p=0.016), re-revision rates (28.9 vs. 9.1%, p=0.042) and periprosthetic infections as a cause of revision (90.9 vs. 0%, p=0.007). Mortality rates were not significantly different, and no patient died for causes related to infection. Type of surgery (1.5-stage vs. 2-stage) was the only independent predictor of re-revision (odds-ratio 4.0, 95% confidence-interval 1.02–16.16, p=0.046).Our data suggests that patients who undergo 1.5-stage exchange arthroplasty have a significantly higher re-revision rate (mostly due to infection) when compared to 2-stage patients. We acknowledge potential benefits of the 1.5-stage strategy, especially in high-risk patients since it involves single surgery. However, higher re-revision rates must be considered when counseling patients.

ONE-STAGE VERSUS TWO-STAGE REVISION HIP ARTHROPLASTY: CAN WE CONFIRM THE DATA FROM META-ANALYSIS IN REAL-WORLD REGISTRY DATA?

Studies and meta-analyses worldwide show an increased use of one-stage revisions for treating periprosthetic hip infections, often yielding comparable or better outcomes than two-stage revisions. However, it remains unclear if these successful results can be consistently achieved nationwide besides large centers.This observational cohort study used data from the German Arthroplasty Registry (EPRD) to compare the mortality and re-revision rates between one-stage (n=8183) and two-stage (n=657) first-time revision total hip arthroplasty (RTHA). Kaplan-Meier estimates were applied to evaluate the re-revision rate and cumulative mortality for RTHA.There was a significant difference in mortality between one-stage and two-stage RTHA (p=0.02). One-year post-surgery, the mortality rate was 9.4% for one-stage revisions and 5.5% for two-stage revisions. At the five-year follow-up, the mortality rate for one-stage revisions was 25.5%, compared to 20.0% for two-stage revisions. No significant differences (p=0.30) were found in re-revision rates between one-stage and two-stage revisions after one year (one-stage 16.5% vs. two-stage 13.5%) or five years (one-stage 21.6% vs. two-stage 20.8%). For multiple revisions, the mortality differences were even larger (p&lt;0.001), with a one-year mortality rate of 12.8% for one-stage RTHA and 5.7% for two-stage RTHA.Despite the excellent results of one-stage RTHA in the literature from individual large centers, it shows a significantly higher mortality rate with equal re-revision rate compared to two-stage revision in the nationwide care besides large centers. Significant differences can already be seen within the first year, indicating an increased perioperative mortality for one-stage revision, which might be explained by longer surgery duration, blood-loss and patient selection or maybe a lack of experience concerning proper surgical debridement for one-stage revision. This illustrates the need to establish centers for joint-revision surgery that provide interdisciplinary care and high case numbers to improve perioperative outcomes.

Concerns with alumina bipolar hemiarthroplasties compared to metal bipolar hemiarthroplasties when performed for nontraumatic osteonecrosis of the femoral head.

A nationwide multicenter follow-up cohort study of hip replacement arthroplasties performed for nontraumatic osteonecrosis of the femoral head (ONFH) aimed to answer the following questions: What factors were associated with need for reoperation? Although many modifications were made in bipolar hemiarthroplasties (BPs) to improve their durability, could we find any evidence of their efficacy? Excluding 58 infected hips and 43 ABS THAs with very poor survivorship, we analyzed 7393 arthroplasties; 6284 total hip arthroplasties (THAs), 886 BPs, 188 total resurfacing arthroplasties, and 35 hemi-resurfacing arthroplasties (hRSs). In the 886 BPs, 440 hips had a smooth small-diameter prosthetic neck (nBPs), 667 hips had a smooth neck (sBPs), 116 hips had highly cross-linked polyethylene in the outer head (hBPs), and 238 hips had an outer head whose outer surface was alumina ceramic (aBPs) (648 hips had an outer head whose outer surface was metal [mBPs]). Multivariate analyses using a Cox proportional-hazard model analyzed risk factors. Follow-up ranged from 0.1 to 27 (average, 6.9) years, during which 265 hips (3.6%) needed reoperation. Combined systemic steroid use and excessive alcohol consumption and lateral approach were associated with higher risks, aBPs were less durable than THAs or mBPs, and hRSs were inferior to the others. Regarding BPs, the following divisions did not influence their survivorship; nBP or not, sBP or not, and hBP or not. Factors associated with reoperation risk were identified as described above. The modifications made in BPs did not improve their durability, but aBPs made it worse. Level III, therapeutic cohort study.

Candida parapsilosis in Late Prosthetic Joint Infections Among Immunocompetent Patients: A Case Series.

Fungal prosthetic joint infections (PJIs) are very rare in immunocompetent patients. PJI can present either early, delayed, or as late chronic infections. Diagnosis of fungal PJI presenting late is challenging due to the difficulty in isolation as well as the clinical presentation very similar to an aseptic loosening. There are no clear guidelines regarding the management of these patients. We present five cases of Candida parapsilosis PJI presenting as late chronic infections. All five patients were culture-negative preoperatively, immunocompetent, and with good soft-tissue condition. There were three infected knee prostheses and two infected hip hemiarthroplasty. All of them were treated with extensive debridement, meticulous sampling, and extended culture. We treated all of them with long-term antifungals without any disease reactivation or recurrence till the last follow-up. Fungal infection should be suspected in immunocompetent patients presenting early with features of aseptic loosening but without typical signs of periprosthetic infection. Revision with long-term suppressive therapy can give good results in these patients.

Periprosthetic hip infection: Current concepts and the Wrightington experience

Total hip arthroplasty (THA) is a highly successful operation performed worldwide in increasing numbers for a wide range of indications. There has been a corresponding rise in the incidence of periprosthetic joint infection of the hip (PJIH), which is a devastating complication.There is a significant variation in the definition, diagnosis and management of PJIH largely due to a lack of high-level evidence. The current standard of practice is largely based on cohort studies from high-volume centres, consensus publications amongst subject experts, and national guidance. This review describes our philosophy and practical approach of managing PJIH at a regional tertiary high-volume joint replacement centre.