Infected Hip Research Articles

Effect of the method of anesthetic aid on cellular immunity in periprosthetic infection of the hip joint: : a prospective open randomized study

BACKGROUND: Periprosthetic infection after primary hip replacement is a serious complication. For the anesthetic support of revision operations, both general and neuroaxial anesthesia methods can be used. The question of choosing an anesthetic aid that, with adequate modulation of the operational stress response, would have a minimal immunosuppressive effect is relevant.
 AIM: To examine the effect of general and combined spinalepidural anesthesia during revision operations in patients with periprosthetic hip joint infection on the parameters of cellular immunity.
 MATERIALS AND METHODS: An open prospective randomized study was performed on 25 patients (11 women and 14 men). The patients underwent surgical interventions of revision prosthetics with the replacement of all components of the prosthesis. Group 1 (n=10) underwent general anesthesia (GA), and group 2 (n=15) underwent surgery under combined spinalepidural anesthesia (CSEA). The indices of cellular immunity, namely, CD4+, CD8+, CD4+/CD8+, and B-lymphocytes, were evaluated. Blood sampling was performed in the morning on the day of surgery and then on days 1, 3, 5, and 7 after surgery.
 RESULTS: The CD4+ (%) level in the CSEA group was significantly higher than in the GA group on days 3 and 7 after surgery (p 0.05). Changes in the percentage of CD8+ lymphocytes, the immunoregulatory index, and the percentage of B-lymphocytes between the groups had no statistically significant differences.
 CONCLUSION: The CD4+ (%) level in the CSEA group was significantly higher than that in the GA group on days 3 and 7 after surgery (p 0.05). Statistically significant differences in the dynamics of CD8+, immunoregulatory index, and B-lymphocytes were not found, which may indicate a lesser effect of the type of anesthesia on these indicators.

Partial Two-Stage Exchange for Infected Total Hip Arthroplasty: A Treatment to Take into Account.

Two-stage revision is the gold standard for chronic periprosthetic joint infection (PJI). The removal of well-fixed implants, especially the femoral component, can be extremely difficult and additional osteotomies may be needed, which is time-consuming and results in bone stock loss. When the femoral stem is osseointegrated, there is no clear indication for the use of partial two-stage revision. The primary objective was to assess infection eradication after surgery. Retrospective study of specific case series. A total of eight patients with a chronic uncemented PJI, in the setting of complex revision surgeries, were treated with partial two-stage revision, which included selective retention of the well-fixed femoral component and complete acetabular removal. Stem retention was carried out regardless of the bacteria or associated comorbidities. All patients were re-revision cases with at least two previous surgeries (range, 2-4). Complex revisions were performed in five cases (non-articulated spacer) and simple revisions in three cases (articulated spacer). The minimum follow-up time was 24 months (range, 24-132 months). The infection eradication rate at final follow-up was 100%. Partial two-stage reconstruction is a promising technique for the treatment of chronic PJI in patients with a well-fixed stem and complex re-revision acetabular procedures. Further prospective studies and prolonged follow-ups are required to confirm our results.

Are There Any Changes in the Causative Microorganisms Isolated in the Last Years from Hip and Knee Periprosthetic Joint Infections? Antimicrobial Susceptibility Test Results Analysis.

PJIs following total hip and knee arthroplasty represent severe complications with broad implications, and with significant disability, morbidity, and mortality. To be able to provide correct and effective management of these cases, an accurate diagnosis is needed. Classically, acute PJIs are characterized by a preponderance of virulent microorganisms, and chronic PJIs are characterized by a preponderance of less-virulent pathogens like coagulase-negative staphylococci or Cutibacterium species. This paper aims to analyze if there are any changes in the causative microorganisms isolated in the last years, as well as to provide a subanalysis of the types of PJIs. In this single-center study, we prospectively included all retrospectively consecutive collected data from patients aged over 18 years that were hospitalized from 2016 through 2022, and patients that underwent a joint arthroplasty revision surgery. A standardized diagnostic protocol was used in all cases, and the 2021 EBJIS definition criteria for PJIs was used. 114 patients were included in our analysis; of them, 67 were diagnosed with PJIs, 12 were acute/acute hematogenous, and 55 were chronic PJIs. 49 strains of gram-positive aerobic or microaerophilic cocci and 35 gram-negative aerobic bacilli were isolated. Overall, Staphylococcus aureus was the most common isolated pathogen, followed by coagulase-negative staphylococci (CoNS). All cases of acute/acute hematogenous PJIs were caused by gram-positive aerobic or microaerophilic cocci pathogens. Both Staphylococcus epidermidis and methicillin-resistant S. aureus were involved in 91.66% of the acute/acute hematogenous PJIs cases. 21.8% of the chronic PJIs cases were caused by pathogens belonging to the Enterobacterales group of bacteria, followed by the gram-negative nonfermenting bacilli group of bacteria, which were involved in 18.4% of the cases. 12 chronic cases were polymicrobial. Based on our findings, empiric broad-spectrum antibiotic therapy in acute PJIs could be focused on the bacteria belonging to the gram-positive aerobic or microaerophilic cocci, but the results should be analyzed carefully, and the local resistance of the pathogens should be taken into consideration.

The effect of perioperative specialized enteral nutrition on postoperative period after redo surgeries in patients with periprosthetic hip joint infection

The effect of perioperative specialized enteral nutrition on postoperative period after redo surgeries in patients with periprosthetic hip joint infection

Do Changes in Hemoglobin and C-Reactive Protein Levels in Patients With Hip Tuberculosis After Two Months of Treatment Predict Tubercle Bacilli Deletion?

Background and objective Tuberculosis (TB) of the hip refers to the hip infection caused bytubercle bacilli. Treatment for hip TB includes anti-TB medications, surgery to remove joint abscesses, and orthopedic surgery. It is necessary to conduct tests to confirm that the tubercle bacilli have been eradicated following the treatments. In this study, we aimed to assess the change in hemoglobin and C-reactive protein (CRP) serum levels in patients with hip TB before and two months after receiving specific treatments. We sought to determine whether they are significant tests for the treatment prognosis of hip TB. Methods We employed a prospective cohort design for this study. It was conducted at National Lung Hospital, Hanoi, and involved 24 hip TB patients with intra-articular abscesses who were treated at the center during the period from October 2016 to October 2021. Blood hemoglobin, CRP serum level, and abscesses on hip MRI were assessed before and two months after treatments. Hemoglobin was examined by spectrophotometry, and CRP serum was measured using the immunoturbidimetric method. Results Before treatments, the average hemoglobin level in the patients was 11.48 ± 1.85 g/dl; the average CRP serum level was 63.53 ± 36.47 mg/l. After two months of treatments, the average hemoglobin level increased significantly to 13.22 ± 1.36 g/dl, while the average CRP level reduced significantly to 12.55 ± 11.34 mg/l. However, five cases displayed abnormal findings. These five individuals continued to have intra-articular abscesses. Conclusion In individuals who reacted well to the therapy, bloodhemoglobin and CRP serum levels improved. Blood hemoglobin and serum CRP assays can be utilized to monitor outcomes in hip TB therapy.

Short-term Outcomes of Patients with Fragility Hip Fractures Infected with SARS-CoV-2 Managed in a COVID-19 Referral Hospital with an Orthogeriatric Team

Objectives. Presence of COVID-19 infection in patients with acute fragility hip fracture complicates the decision-making process in the management of these patients. This study aims to describe outcomes of patients with coexisting fragility hip fracture and COVID-19 infection who underwent surgery.Methods. In this retrospective study, the patient database of a university hospital designated as a COVID-19 referral center with an orthogeriatric team was reviewed to determine the mortality and morbidity rates, and short-term functional outcomes of patients with coexisting COVID-19 and acute fragility hip fracture who underwent surgery.Results. A total of 18 patients were admitted with COVID-19 infection and acute fragility hip fracture – 12 hadsurgery. Mean injury-to-admission and admission-to-surgery intervals were 6.5 and 4.8 days, respectively. Mostpatients (91.7%) had an incidental finding of SARS-CoV-2 infection. Mean ASA score was 2.9. Arthroplasty wasdone in all patients with a mean operative time of 155.8 minutes and an average blood loss of 366.7 mL. Thirty-day mortality and morbidity rates were 16.7% and 33.3%, respectively. Mean EuroQoL overall health score was 79.3.Conclusion. A multidisciplinary team approach is recommended to expedite timely surgery prior to the onset ofclinical deterioration. Asymptomatic and mildly symptomatic patients with acute fragility hip fracture are candidates for urgent surgical intervention even in the presence of COVID-19 infection

982. Microbiologic Composition and Failure Rates of Prosthetic Hip and Knee Infections Managed with Debridement, Antibiotics and Implant Retention.

Abstract Background Success rates of prosthetic joint infections (PJI) managed by debridement, antibiotics, and implant retention (DAIR) vary according to recent literature. Our aim is to evaluate the success/failure rate of PJI managed by DAIR with respect to the microbiologic composition, antimicrobial selection, and treatment duration. Methods A single-center retrospective cross-sectional study was conducted from January 2017 to December 2021. All patients ≥ 18 years of age who underwent DAIR were identified from an existing internal database. Patients were included if they received at least 3 weeks but no more than 8 weeks of parenteral therapy with or without consolidative or chronic therapy. Data collection was completed via chart review including demographics, microbiologic data, antimicrobial therapy and outcomes. Failure was defined as any subsequent need for surgical intervention, infection related mortality, persistent infection, new infection, or probable treatment failure measured at a minimum of two year follow up from index DAIR. Results A total of 49 patients were included (15 hip, 34 knee) with 21 failures (43%) and 28 in remission (57%). Table 1 shows the breakdown of cases including time to PJI from index procedure, duration of symptoms prior to DAIR procedure, chronic antibiotics, and microbiologic composition. DAIR procedure occurred < 3 weeks from onset of symptoms in 43 patients (88%) but no observed difference in outcomes was seen based on patient’s time to PJI or symptoms duration. Staphylococcus aureus was the most common pathogen identified, n=14 (29%) and encompassed 43% of the total failures. Mean antimicrobial therapy was 42 and 180 days for parenteral and oral respectively with 17 (35%) patients on chronic/indefinite therapy. Of the failures, 48% occurred while on parenteral therapy. Need for further surgical intervention was the leading cause of failure at 37%. Conclusion Despite early intervention, our study found a failure rate of 43% in patients with knee and hip PJI managed with DAIR. We observed similar success rates across multiple organisms and antimicrobial treatments. Further evaluation of failure cases would help to inform which patients are the best candidates for DAIR procedures. Disclosures All Authors: No reported disclosures.

991. Single Center, Exploratory, Open-label Prospective Study Using the Minimally Invasive LysinDAIR Procedure (Lysin Administration During an Arthroscopic DAIR Procedure) in Patients with Suspected Relapsing Chronic Coagulase-Negative Staphylococci (CNS) Prosthetic Hip Infection (PHI)

Abstract Background Exebacase, a recombinant staphylococcal lysin, has: (i) reported proof-of-concept data in Phase II in S. aureus bacteremia; (ii) demonstrated antibiofilm activity in vitro against S. epidermidis; and (iii) been used as salvage therapy in 4 patients with relapsing multidrug-resistant (MDR) S. epidermidis knee prosthetic joint infection (PJI) using the LysinDAIR (arthroscopic administration of exebacase [Lysin] with Debridement and Antibiotics Implant Retention) procedure. Surgical treatment of recurrent PHIs has high risk of morbidity and loss of function. We now report our experience with the LysinDAIR procedure for PHIs. Methods We performed a single center, exploratory, open-label prospective study using LysinDAIR and suppressive antimicrobial therapy (SAT) in patients with recurrent, chronic (inoculation >3 months prior to treatment) CNS PHI. In agreement with the French Health authority, exebacase (2 to 3.5 total mg in 30-50 ml [∼0.067 – 0.075 mg/ml]) was arthroscopically administered directly into the joint. Results Three consecutive patients were included (55 to 75 years). All had previous iterative hip prosthesis exchange with a high total number of surgeries (from 6 to 10) and recent persistent or intermittent fistula (Figure). All refused hip prosthesis explantation or surgeon considered explantation too high risk for loss of function and severe post-operative complications. Patients A and B had MDR S. epidermidis; Patient B had P. aeruginosa co-infection at the time of LysinDAIR. Patient C had a prior persistent S. lugdunensis PHI and relapse on arthrocentesis; K. pneumoniae was cultured at the time of LysinDAIR. No adverse events related to exebacase or the procedure were reported. At 2 years follow up, all patients had resolution of fistula and no clinical signs of infection on SAT (tedizolid (+/- ciprofloxacin [Patient B] or cotrimoxazole [Patient C]). Description of the patients treated with the LysinDAIR procedure Local signs of infection with discharge of the three patients (A, B and C) with complex relapsing prosthetic hip infection with X-ray before the LysinDAIR procedure and at 2 years of follow-up Conclusion The LysinDAIR procedure was easy-to-perform, safe and may have therapeutic potential to facilitate the success of SAT salvage therapy for chronic relapsing CNS PJIs, and potential cure of initial chronic PJI. Randomized clinical trials evaluating the LysinDAIR procedure in these clinical situations are clearly warranted. Disclosures Tristan Ferry, MD, PhD, Contrafect: Advisor/Consultant Camille Kolenda, n/a, Contrafect: Research grant frederic Laurent, n/a, Contrafect: Research grant cara cassino, n/a, Contrafect: Employee.

A systematic review and meta-analysis comparing intrawound vancomycin powder and povidone iodine lavage in the prevention of periprosthetic joint infection of hip and knee arthroplasties

BackgroundFocus on reviewing a vigorous research effort to improve the safety profile of vancomycin powder (VP) and its optimal dose in reducing periprosthetic joint infection (PJI) is the need of the hour. This systematic review and meta-analysis attempt to explore the ongoing use of VP and VP + povidone iodine (PI) lavage to prevent PJI of hip/knee arthroplasties and highlights its challenges among the orthopedic community about the existence of the major organism and its frequency in total joint arthroplasty (TJA) patients. MethodsWe searched PubMed/MEDLINE, EMBASE databases regarding the outcomes of vancomycin powder (VP) and VP + povidone iodine (PI) combination in preventing periprosthetic joint infection of hip and knee arthroplasties. ResultsIn 5 of 7 studies, the combination of vancomycin powder (VP) and povidone iodine (PI) lavage have shown a lower risk of periprosthetic joint infection (PJI) in acute and high-risk hip and knee arthroplasties patients, with less or without serious adverse events and readmissions; while four of seven studies using VP-only found increasing rates of PJI in primary total knee arthroplasty and partial hip replacement in elderly patients with comorbidities, and significantly causes aseptic wound complications compared to the control group. ConclusionsIntra-articular vancomycin powder (VP) and povidone iodine (PI) lavage showed a significant reduction of periprosthetic joint infection in primary and revision total joint arthroplasty. Before its widespread use in clinical settings, prospective randomized studies and, most importantly, its long-term efficacy and safety are recommended.

Rapidly progressive femoral head necrosis due to post-traumatic Brucella hip infection: a case report

Brucellosis is a common zoonotic infectious disease worldwide that can affect almost all organs in the human body. Osteonecrosis of the femoral head has numerous possible causes. Patients usually experience movement disorders, severe pain, and an extremely high disability rate. We herein describe a 32-year-old male farmer living in Shanxi, China who accidentally injured his right hip while working. After 1 month of rest, the pain in the right hip was relieved, and the patient began to walk again. However, after 2 months of walking, he developed aggravated pain and claudication in the right lower limb. Examination revealed shortening of the right lower limb. We carried out a comprehensive and systematic examination and performed total hip arthroplasty. Hip trauma with Brucella infection may progress to osteonecrosis of the femoral head in a short period of time without typical symptoms of Brucella infection. Systematic examination and treatment should be performed at an early stage to prevent the eventual deterioration of the disease and serious complications that are difficult to treat.

Impact of Antibiotic-Impregnated Spacer Design in the Treatment of Periprosthetic Hip Infection.

Although 2-stage exchange arthroplasty, consisting of temporary insertion of an antibiotic-impregnated cement spacer (AICS), is considered the standard of care for chronic periprosthetic joint infection (PJI) in total hip arthroplasty (THA), a consensus on the AICS design has not yet been established. Ceramic-on-polyethylene AICSs (Poly-AICS) are theorized to cause less pain and better function than cement-on-bone AICS (CemB-AICS) but use non-antibiotic-impregnated components that may harbor bacteria. This study evaluates the impact of spacer design on infection-free survivorship following THA reimplantation as well as pain and function during the interim AICS stage. A retrospective review was performed of all cases of THA PJI treated with either Poly-AICS or CemB-AICS at a single high-volume academic center. Data were collected until the final follow-up after THA reimplantation with an average follow-up duration of 2.6 years. The primary outcome was infection-free survivorship after the final reimplantation. Secondary outcomes included postoperative pain scores, opioid use, time to ambulation, length of stay, complications, and discharge disposition. A total of 99 cases (67 CemB-AICS; 32 Poly-AICS) were included. There were no baseline differences between the 2 groups. There were no differences in infection-free survivorship after reimplantation in survivorship curve comparisons (P= .122) and no differences in postoperative inpatient pain scores, opioid use, length of stay, time to ambulation, complications, or discharge disposition during the AICS stage. Patients with THA PJI treated with Poly-AICS did not have worse infection-related outcomes despite the use of non-antibiotic-impregnated components but also did not appear to have less pain or improved function during the early AICS stage.

Is hip resection arthroplasty a successful definitive treatment?

PurposeHip resection arthroplasty as a definitive treatment is an uncommon indication, although still in use selectively. This study evaluates a cohort of patients who have undergone hip resection arthroplasty surgery indicated as a definitive treatment, in order to assess the rate of re-operation, the rate of infection, and the mortality rates. MethodsWe conducted a retrospective, observational, descriptive analysis of a cohort of patients who had undergone a hip resection arthroplasty intended as a definitive treatment, in two University Hospitals from 1994 to 2020. The exclusion criteria were the implantation of a hip cement spacer, or a temporary hip resection arthroplasty in patients undergoing a two-staged surgical approach. We found 26 cases of hip resection arthroplasty. We recorded the indications for a definitive hip resection arthroplasty, the outcomes and complications, and analyzed the success of the hip resection arthroplasty as a definitive surgery using a Kaplan-Meier curve. ResultsSeven cases (26.9%) required a re-operation after the hip resection arthroplasty, four cases for persistent hip infection, and in the three remaining a conversion to a total hip arthroplasty was re-considered due to a good medical evolution and non-tolerance to the low functional outcome. The mortality rate was 61.5% (27 days–20 years), with a 19.2% mortality rate in the first 5 years. All the cases that required another surgery after the hip resection arthroplasty were re-operated within the first 18 months. ConclusionUnfortunately, hip resection arthroplasty continues to show elevated re-operation rate and early mortality rate, as well as low functional outcomes. Two-staged hip revision arthroplasty is the surgical treatment of choice in patients suffering from a periprosthetic joint infection, however we believe that hip resection arthroplasty should be considered in fragile patients, who have endured multiple revision surgeries, or their comorbidities make them unfit from further surgeries.

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Risk Factors for Deep Infection and Conversion Total Hip Arthroplasty After Operative Combined Pelvic Ring and Acetabular Fractures.

To determine risk factors for deep infection and conversion total hip arthroplasty (THA) after operative management of combined pelvic ring and acetabular injuries. Retrospective case control study. Level 1 trauma center. We reviewed 150 operative combined pelvic ring and acetabular injuries at our institution from 2010 to 2019, with an average follow-up of 690 (90-3282) days. Deep infection and conversion THA. Patients who developed deep infection (N = 17, 11.3%) had higher rates of hip dislocation ( P = 0.030), intraoperative transfusion ( P = 0.030), higher body mass index (BMI) ( P = 0.046), increased estimated blood loss ( P < 0.001), more intraoperative units transfused ( P = 0.004), and longer operative times ( P = 0.035). Of the 84 patients with 1-year follow-up, 24 (28.6%) required conversion to THA. Patients requiring conversion THA were older ( P = 0.022) and had higher rates of transverse posterior wall fracture pattern ( P = 0.034), posterior wall involvement ( P < 0.001), hip dislocation ( P = 0.031), wall comminution ( P = 0.002), and increased estimated blood loss ( P = 0.024). The order of the pelvic ring versus acetabular fixation did not affect rates of conversion to THA ( P = 0.109). Multiple logistic regression showed that an increased number of intraoperative units transfused [adjusted odds ratio (aOR) = 1.56, 95% confidence interval (CI) = 1.16-2.09, P = 0.003] and higher BMI (aOR = 1.10, 95% CI = 1.01-1.16, P = 0.024) were independently associated with an increased odds of deep infection. Posterior wall involvement was independently associated with an increased odds of conversion THA (aOR = 5.73, 95% CI = 1.17-27.04, P = 0.031). Rates of deep infection and conversion THA after operative fixation of combined injuries were 11.3% and 28.6%, respectively. Higher average BMI and number of intraoperative units of blood transfused were independently associated with deep infection, whereas posterior wall involvement was independently associated with conversion to THA in these patients. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Wound fluid ceftriaxone concentrations after local application with calcium sulphate as carrier material in the treatment of orthopaedic device-associated hip infections

There is a considerable challenge in treating bone infections and orthopaedic device-associated infection (ODAI), partly due to impaired penetration of systemically administrated antibiotics at the site of infection. This may be circumvented by local drug administration. Knowledge of the release kinetics from any carrier material is essential for proper application. Ceftriaxone shows a particular constant release from calcium sulphate (CaSO4) in vitro, and is particularly effective against streptococci and a large portion of Gram-negative bacteria. We present the clinical release kinetics of ceftriaxone-loaded CaSO4 applied locally to treat ODAI. A total of 30 operations with ceftriaxone-loaded CaSO4 had been performed in 28 patients. Ceftriaxone was applied as a single local antibiotic in 21 operations and combined with vancomycin in eight operations, and in an additional operation with vancomycin and amphotericin B. Sampling of wound fluid was performed from drains or aspirations. Ceftriaxone concentrations were measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS). A total of 37 wound fluid concentrations from 16 operations performed in 14 patients were collected. The ceftriaxone concentrations remained approximately within a range of 100 to 200 mg/l up to three weeks. The median concentration was 108.9 mg/l (interquartile range 98.8 to 142.5) within the first ten days. No systemic adverse reactions were observed. Our study highlights new clinical data of locally administered ceftriaxone with CaSO4 as carrier material. The near-constant release of ceftriaxone from CaSO4 observed in vitro could be confirmed in vivo. The concentrations remained below known local toxicity thresholds.Cite this article: Bone Joint Res2022;11(11):835-842.

Constrained acetabular liners are a viable option in second-stage re-implantation for chronic infected total hip arthroplasty with abductor or greater trochanter deficiency and large acetabular bone defects

BackgroundAbductor mechanism deficiency is a clear indication for using constrained acetabular liners (CALs), and large acetabular bone defects are considered a relative contraindication to CALs. We report the results of using CALs in special cases in which abductor or greater trochanter deficiency was accompanied by large acetabular bone defects at second-stage re-implantation for chronic infected total hip arthroplasty (THA).MethodsBetween January 2010 and January 2018, 19 patients who used CALs at second-stage re-implantation and had abductor or greater trochanter deficiency and large acetabular bone defects were included in this study. We followed up with the clinical and radiological results of these patients. Complications and infection-related information were also recorded.ResultsEight patients, 4 patients, and 7 patients had Paprosky type IIB, type IIC, and type IIIA acetabular bone defects at second-stage re-implantation, respectively. The indication for using CALs was abductor deficiency in 14 patients and greater trochanter deficiency in the other 5 patients. The mean follow-up was 74.4 months (range 50–96). The mean Harris Hip Score (HHS) was 76.3 points (range 62–86) at the last follow-up. Three patients presented acetabular radiolucent lines with no progress: zone 3, zone 3 and zone 2 and 3, respectively. One patient suffered transient sciatic nerve palsy. There was no dislocation, failure of the CALs, reoperation, or recurrence of infection.ConclusionOur results suggested that for screened patients, CALs are a viable option in second-stage re-implantation for chronic infected THA with abductor or greater trochanter deficiency and large bone defects.

Low-dose spinal block combined with epidural volume extension in a high-risk cardiac patient: A case-based systematic literature review.

Anesthetic management of patients with severe cardiac disease can be challenging during prolonged surgical procedures. Thus, alternative neuraxial anesthetic techniques have been described to avoid general anesthesia in these patients. A case-based systematic literature review on low-dose spinal block combined with different methods of epidural block extension in high-risk cardiac patients was performed. We describe the successful management of a patient with poor left ventricular function who underwent excision arthroplasty of an infected hip prosthesis under low-dose spinal block with levobupivacaine 5 mg and fentanyl 15 μg combined with saline epidural volume extension (EVE). Epidural ropivacaine 0.75% was administered as a bolus of 5 ml followed by an infusion at 5 ml/h later during the course of surgery. Although continuous spinal anesthesia (CSA) or epidural anesthesia may limit hemodynamic instability, the possibility of devastating central nervous system infection may prevent CSA use, and epidural block alone may be less reliable than CSA. Epidural block alone may require large volumes of concentrated local anesthetic to obtain sacral block, which may produce hemodynamic instability. The EVE, particularly using saline EVE, has rarely been described in high-risk cardiac patients as an alternative to CSA or epidural block alone, with the intention to avoid general anesthesia, but it has demonstrated efficacy and a low rate of complications. Hemodynamic stability was maintained in most cases.

Fungal Periprosthetic Hip Joint Infections.

Introduction: Fungal hip prosthetic joint infections (PJIs) are rare but severe infections. Their incidence has increased in the last decades due to the aging population, as well as due to the increased number of immunosuppressed hosts. The present review of all published fungal PJIs in hip arthroplasties aims to present as much data as possible for both medical and surgical treatment options, so that the best applicable management may be concluded. Methods: A meticulous review of all published fungal hip PJIs was conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical management as well as the infection outcome was recorded. Results: A total of 89 patients suffering fungal hip PJI were identified. The patients’ mean age was 66.9 years. The mean time from initial arthroplasty to onset of symptoms was 69.3 months, while 40.4% of the patients were immunocompromised. The most common imaging method indicating diagnosis was plain X-ray or CT scan (20.2%), while definite diagnosis had become possible through cultures in most cases (98.9%), and/or histology (44.9%). The most frequently isolated fungus was C. albicans (49.4%), followed by C. parapsilosis (18%) and C. glabrata (12.4%), while bacterial co-infection was present in 32 cases (36%). Two-stage revision arthroplasty (TSRA) was the most commonly performed procedure (52.8%), with mean time between the two stages = 7.9 months. Regarding antifungal treatment (AFT), fluconazole was the preferred agent (62.9%), followed by amphotericin B (36%), while the mean duration of AFT was 5.1 months. Outcome was successful in 68 cases (76.4%). Conclusions: Both diagnosis and management of fungal PJIs in patients having undergone total hip arthroplasty are quite demanding. A multidisciplinary approach is of utmost importance, since the combination of AFT and TSRA appears to be the proper treatment method.

Transfusion Rates in the Operative Treatment of Prosthetic Hip and Knee Infection.

Surgery for prosthetic joint infection (PJI) can often lead to significant blood loss, necessitating allogeneic blood transfusion (ABT). The use of ABT is associated with higher rates of morbidity and death in revision total joint arthroplasty, particularly in the treatment of PJI. We compared ABT rates by procedure type among patients treated for PJI. We retrospectively reviewed 143 operative cases of hip and knee PJI performed at our institution between 2016 and 2018. Procedures were categorized as irrigation and debridement (I&D) with modular component exchange (modular component exchange), explantation with I&D and placement of an antibiotic spacer (explantation), I&D with antibiotic spacer exchange (spacer exchange), or antibiotic spacer removal and prosthetic reimplantation (reimplantation). Rates of ABT and the number of units transfused were assessed. Factors associated with ABT were assessed with a multilevel mixed-effects regression model. Of the cases, 77 (54%) required ABT. The highest rates of ABT occurred during explantation (74%) and spacer exchange (72%), followed by reimplantation (36%) and modular component exchange (33%). A lower preoperative hemoglobin level was associated with higher odds of ABT. Explantation, reimplantation, and spacer exchange were associated with greater odds of ABT. Antibiotic spacer exchange and explantation were associated with greater odds of multiple-unit transfusion. Rates of ABT remain high in the surgical treatment of PJI. Antibiotic spacer exchange and explantation procedures had high rates of multiple-unit transfusions, and additional units of blood should be made available. Preoperative anemia should be treated when possible, and further refinement of blood management protocols for prosthetic joint infection is necessary. [Orthopedics. 2022;45(6):353-359.].

Outcomes of revision arthroplasty for hip joint infection in matched groups of HIV-positive and HIV-negative patients.....

Several studies reported on periprosthetic infection after primary THA in HIV-positive patients, but very few showed the results of its revision. The aim was to compare primary and secondary clinical outcomes after revision arthroplasty for hip joint infection in matched groups of HIV-infected and HIV-negative patients. Using the hospital database, thirteen HIV-positive patients (13 infected hips) and thirteen HIV-negative patients of the matched control group (13 infected hips) were identified and their records were studied retrospectively. They underwent revision surgery aimed at infection arrest and total hip replacement due to infection developed after primary THA or infected spacers. Harris Hip Score, reinfection rate, limb shortening, and definite outcomes were evaluated with Wilcoxon, Mann-Whitney, and Chi-squared tests. Spacers with antibiotics were implanted in patients of both groups at the first step of revision, except one HIV-infected patient who had resection arthroplasty. The mean follow-up was 29.4±2.7 and 33.±2.9 months for the HIV-group and control group, respectively. Three patients of the HIV-group completed two-stage revision arthroplasty versus ten patients from the control group. Re-infection rate was higher in the HIV-group. At final follow-ups, the mean HHS was significantly different (53±3.2 points in the HIV-group versus 79.14±3.1 points in the control group) along with limb length discrepancy (3.71±0.43 versus 1.4±0.32). Both primary and secondary clinical outcomes of revision arthroplasty for hip joint infection in HIV-positive patients were significantly worse than in the matched group of HIV-negative patients. Revisions in HIV-positive group resulted in a higher reinfection rate, a small number of definite two-stage revisions, and lower functional scores.