Infected Total Hip Arthroplasty Research Articles

Influential literatures in periprosthetic infection following joint arthroplasty: A bibliometric review

The objective of this bibliometric literature review was to identify and analyze the most frequently cited manuscripts on the topic of periprosthetic joint infection. Periprosthetic infection following joint arthroplasty is a complication leading to rising rates of mortality and increasing economic strain. No prior study has evaluated the most impactful literature on the topic of periprosthetic joint infection (“PJI”) in total hip and knee arthroplasty. Knowledge and appreciation of the most influential publications on this topic can guide and inspire future research endeavors. Using the Clarivate Analytics Web of Science database, the 50 most cited articles related to periprosthetic infection following joint arthroplasty were identified. Numerous metrics including citation frequency, year of publication, country of origin, level-of-evidence (LOE), article type, and contributing authors/institutions were recorded. The seven most cited articles (per year) during the past 10 years were also identified. The years of publications of the articles included in the final analysis ranged from 1969 to 2014. “Current concepts: Prosthetic-joint infections” by Zimmerli et al. was the most frequently cited article. Level of Evidence (“LOE”) of 2 and 3 were the most common. Clinical outcomes was the most common article type. Mayo Clinic and Thomas Jefferson University produced the most publications. Hanssen and Parvisi were the most productive authors. 2000–2009 ( n = 25) was the most prolific decade in terms of number of publications. Using citation analysis as an indication of influence, the most influential articles on periprosthetic joint infection were highlighted. Analysis of the most recognized publication on PJI provides an enhanced understanding of the diagnosis, treatment, and future research of PJI. Future studies may combine the search results of multiple databases including Scopus, Web of Science and PubMed to rectify any discrepancies in citation data and to capture additional literature on PJI.

High mortality following revision hip arthroplasty for periprosthetic femoral fracture.

To determine mortality risk after first revision total hip arthroplasty (THA) for periprosthetic femoral fracture (PFF), and to compare this to mortality risk after primary and first revision THA for other common indications. The study cohort consisted of THAs recorded in the National Joint Registry between 2003 and 2015, linked to national mortality data. First revision THAs for PFF, infection, dislocation, and aseptic loosening were identified. We used a flexible parametric model to estimate the cumulative incidence function of death at 90 days, one year, and five years following first revision THA and primary THA, in the presence of further revision as a competing risk. Analysis covariates were age, sex, and American Society of Anesthesiologists (ASA) grade. A total of 675,078 primary and 74,223 first revision THAs were included (of which 6,131 were performed for PFF). Following revision for PFF, mortality ranged from 9% at 90 days, 21% at one year, and 60% at five years in the highest risk group (males, ≥ 75 years, ASA ≥ 3) to 0.6%, 1.4%, and 5.5%, respectively, for the lowest risk group (females, < 75 years, ASA ≤ 2). Mortality was greater in all groups following first revision THA for PFF than for primary THA. Compared to mortality risk after first revision THA for infection, dislocation, or aseptic loosening, revision for PFF was associated with higher five-year mortality in all groups except males < 75 years with an ASA ≤ 2. Mortality risk after revision THA for PFF is high, reaching 60% at five years in the highest risk patient group. In comparison to other common indications for revision, PFF demonstrated the highest overall risk of mortality at five years. These estimates can be used in the surgical decision-making process and when counselling patients and carers regarding surgical risk. Cite this article: Bone Joint J 2020;102-B(12):1670-1674.

Operative approach influences functional outcome after DAIR for infected total hip arthroplasty.

To compare the functional outcome, health-related quality of life (HRQoL), and satisfaction of patients who underwent primary total hip arthroplasty (THA) and a single debridement, antibiotics and implant retention (DAIR) procedure for deep infection, using either the transgluteal or the posterior surgical approach for both procedures. The study was registered at clinicaltrials.gov (ID: NCT03161990) on 15 May 2017. Patients treated with a single DAIR procedure for deep infection through the same operative approach as their primary THA (either the transgluteal or the posterior approach) were identified in the Norwegian Arthroplasty Register and given a questionnaire. Median follow-up after DAIR by questionnaire was 5.5 years in the transgluteal group (n = 87) and 2.5 years in the posterior approach group (n = 102). Patients in the posterior approach group were less likely to limp after the DAIR procedure (17% vs 36% limped all the time; p = 0.005), had a higher mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (80 vs 71; p = 0.013), and were more likely to achieve a patient acceptable symptom state for the WOMAC function score (76% vs 55%; p = 0.002). In a multivariable analysis, the point estimate for the increase in WOMAC function score using the posterior approach was 10.2 (95% CI 3.1 to 17.2; p = 0.005), which is above the minimal clinically important improvement. The patients in the posterior approach group also reported better mean HRQoL scores and were more likely to be satisfied with their hip arthroplasty (77% vs 55%; p = 0.001). In patients treated with a single, successful DAIR procedure for deep infection of a primary THA, the use of the posterior approach in both primary surgery and DAIR was associated with less limping, better functional outcome, better HRQoL, and higher patient satisfaction compared with cases where both were performed using the transgluteal approach. The observed differences in functional outcome and patient satisfaction were clinically relevant. Cite this article: Bone Joint J 2020;102-B(12):1662-1669.

Diagnostic Value of MRI Lamellated Hyperintense Synovitis in Periprosthetic Infection of Hip.

ObjectiveTo investigate the correlation between magnetic resonance imaging (MRI) lamellated hyperintense synovitis and periprosthetic infection of hip arthroplasty and estimate its value in the diagnosis of infection after hip replacement.MethodsA retrospective analysis of 50 patients who underwent MRI from January 2016 to June 2019 after hip replacement was performed. The MRI scanning was performed with a 1.5T clinical imaging unit using SEMAC protocols. A total of 25 patients (cohort 1) showed infected total hip arthroplasty, and 25 patients had non‐infected arthroplasty as controls (cohort 2). Two musculoskeletal radiologists, blinded to the clinical diagnosis, reviewed all the images for the presence of lamellated hyperintense synovitis independently. The cases were rereviewed by each reader after 2 weeks. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated using the first reads. The Kappa statistic was used to assess inter‐observer and intra‐observer reliability.ResultsThe incidence of lamellated hyperintense synovitis was 76%–88% in the experimental group and 8%–16% in the control group. The sensitivity of lamellated hyperintense synovitis for infection was 0.80–0.88 (95% confidence interval [CI]:0.59 – 0.97), the specificity was 0.84~0.92 (95% CI: 0.64 –0.99), the positive predictive value 0.83–0.92 (95% CI: 0.67 – 0.98), the negative predictive value 0.81 – 0.88 (95% CI: 0.65 – 0.96). The agreement between two readers was substantial (Kappa = 0.76, 95% CI: 0.58 – 0.94, P < 0.05). There were moderate inter–observer agreements for both readers, reader 1 (Kappa = 0.48, 95%CI: 0.23 – 0.72, P < 0.05) and reader 2 (Kappa = 0.44，95% CI: 0.19 – 0.69, P < 0.05).ConclusionIn this cohort, the presence of lamellated hyperintense synovitis in the MRI of hip arthroplasty showed high sensitivity and specificity for infection. This sign had substantial intra‐observer reliability and moderate inter‐observer reliability in the classification of the synovial pattern.

Patient-reported Outcome Measures of Revision Total Hip Arthroplasty for Prosthetic Joint Infection is not Inferior to Aseptic Revision Total Hip Arthroplasty.

Introduction:This study aims to investigate whether patients undergoing two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) and one-stage revision THA for aseptic reasons have similar clinical outcomes and patient satisfaction during their post-operative follow-up. We hypothesise that the two-stage revision THA for PJI is associated with poorer outcomes as compared to aseptic revision THA.Materials and Methods:We reviewed prospectively collected data in our tertiary hospital arthroplasty registry and identified patients who underwent revision THA between 2001 and 2014, with a minimum of two years follow-up. The study group (two-stage revision THA for PJI) consists of 23 patients and the control group (one-stage revision THA for aseptic reasons) consists of 231 patients. Patient demographics, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Oxford Hip Score (OHS), Short Form-36 (SF-36) scores and patient reported satisfaction were evaluated. Student’s t-test was used to compare continuous variables between the two groups. Statistical significance was defined as p <0.05.Results:The pre-operative demographics and clinical scores were relatively similar between the two groups of patients. At two years, patients who underwent revision THA for PJI reported a better WOMAC Pain Score and OHS as compared to aseptic revision THA. A similar proportion of patients were satisfied with their results of surgery in both groups (p=0.093).Conclusions:Although patients who underwent revision THA for PJI had poorer pre-operative functional scores (WOMAC function and SF-36 PF), at two years follow-up, these two groups of patients have comparable post-operative outcomes. Interestingly, patients who had revision THA for PJI reported a better clinical outcome in terms of OHS and WOMAC Pain score as compared to the aseptic group. We conclude that the revision THA for PJI is not inferior to aseptic revision THA in terms of patient satisfaction and clinical outcomes.

An Alternative One-Stage Exchange Arthroplasty Technique: For the Chronic Infected Total Hip.

BackgroundThere are various algorithms for the treatment of prosthetic joint infections (PJI). Currently, a two-stage hip exchange is considered the “gold standard” of care for treatment of chronic hip PJIs. However, there has been recent debate whether a one- or two-stage exchange offers the correct treatment. One-stage exchange arthroplasty has particularly gained interest due to less morbidity, mortality, and functional impairment.MethodsIn a retrospective case series, the outcome of patients with chronic hip PJIs treated with our one-stage exchange arthroplasty was analyzed. Between January 2015 and January 2020, eight patients underwent a one-stage exchange hip arthroplasty by a single surgeon at a single institution for a chronically infected total hip arthroplasty (THA). Original diagnosis of PJI was made in accordance with the 2011 version of the Musculoskeletal Infection Society (MSIS) criteria. The femoral stem was cemented with antibiotic-impregnated cement, and the polyethylene acetabular liner was cemented directly onto the acetabular bone with antibiotic-impregnated cement.ResultsOf the eight patients, three were female and five were male with a mean age of 70.5 years (SD 11.2, range 53-87). Six patients (75%) had infection eradication with retention of a stable implant and no additional surgery at a mean follow-up of 35.7 months (range 17-50). One patient (12.5%) underwent closed reduction for a dislocated THA at one month; however, this patient remained infection-free at the most recent follow-up of 41 months. One patient (12.5%) who was the oldest patient (87 years) died 18 days postoperatively. Overall, all living patients (87.5%) retained their one-stage exchange THA. One patient (12.5%, CI 95% 0.3-52.7) required additional surgery in the form of a closed reduction and zero patients (0.0%, CI 95% 0.0-36.9) required additional open surgery. ConclusionSingle-stage exchange arthroplasty with an antibiotic-impregnated cemented femoral stem and antibiotic-impregnated cemented polyethylene acetabular liner may be a useful option for the treatment of chronic hip PJIs. Our case series provides evidence that infection eradication and function preservation are possible using our one-stage exchange arthroplasty technique in a chronically infected THA. However, a multi-center study with randomization is necessary to further validate our results.

Conservative two-stage revision with primary components of infected total hip arthroplasty: An analysis of survival, clinical and radiographic outcomes.

Few studies provide an analysis of conservative two-stage revision of hip periprosthetic joint infection (PJI) and its impact on final outcome. A conservative revision is defined when soft tissues and bone quality enable the use of primary prosthetic components. Data of patients treated for chronic hip PJI who underwent two-stage revision between 2009 and 2016 and had a minimum of 2 years of follow-up were collected. Oxford Hip Score (OHS), Harris Hip Score (HHS) and radiological and microbiological data were retrieved and analysed. Clinical and functional outcome, survival, mortality, eradication, reinfection and re-revision rates within subgroups of patients with primary components and revision components are reported herein. A total of 148 patients underwent two-stage hip exchange with a mean follow-up of 55.6 ± 23.1 months and a mean age at surgery of 64.3 ± 12.7 years. Forty-four percent of patients underwent conservative revision. The mean HHS significantly improved from 40.6 ± 9.4 points to the final value of 87.8 ± 10.5 points (p = .002), and the mean OHS went from 20.3 ± 3.8 points to 40.3 ± 5. points (p< .001). Patients who were treated with primary components or isolated revision stems in the second stage had a significant reduction in surgical times (p< .001). The mortality rate for all causes of death was 6.8%, the eradication rate was 89.9%, the reinfection rate was 4.7% and the reoperation rate was 7.4% without differences between conservative and non-conservative revisions. Two-stage exchange arthroplasty for total hip arthroplasty (THA) PJI is a good strategy that provides satisfactory results, high eradication rates and no further need for revision. The conservative two-stage revision in patients with adequate bone stock represents a feasible option with good results and survival rates.

Low-dose vancomycin-loaded cement spacer for two-stage revision of infected total hip arthroplasty.

Objectives This study aims to evaluate the success rate in terms of eradication of infection and long-term outcomes of two- stage revision arthroplasty with spacers loaded with low-dose vancomycin alone for the treatment of an infected hip arthroplasty.Patients and methods The records of 42 two-stage exchange arthroplasty patients (16 males, 26 females; mean age 61 years; range, 30 to 80 years) treated between January 1999 and January 2009 were included in this retrospective study. In the first stage, following removal of the prosthesis and debridement, a spacer consisting of 1 g of vancomycin per 40 g of cement was placed in the infected joint space. Patients received six weeks of intravenous antibiotics according to intraoperative cultures. After cessation of systemic antibiotic treatment, with normal C-reactive protein and erythrocyte sedimentation rate levels, second stage surgery with cementless components was performed.Results The mean follow-up duration was seven (range, 3 to 13) years. Two patients (4.7%) developed re-infection after two-stage reimplantation and one patient underwent a resection arthroplasty after repeated debridements. Five years of survival was 92.9% with Kaplan-Meier survival analysis.ConclusionFor chronic infected total hip revisions, two-stage revision arthroplasty with low-dose vancomycin impregnated cement spacers have comparable re-infection and success rates. Low-dose vancomycin promotes effective infection control and reduces antibiotic toxicity.

Dual-mobility cups could yield lesser infections than conventional cups: a meta-analysis of comparative studies.

Dual-mobility cups (DMC) are gaining popularity mainly for their reduced rate of dislocation following total hip arthroplasty (THA). Currently, indication for DMC use extends beyond patients with high risk of dislocation or revision THA cases. Many authors reported DMC outcomes in primary THA for all aetiologies. However, some reports claimed that the use of DMC is accompanied with higher rates of infection compared with conventional cups (CC) in both primary and revision THA. Does the use of DMC generate higher rates of infection when compared with conventional cups? The aim of this meta-analysis was to look for significant difference in the rate of post-operative infection between DMC cups and conventional cups. MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar were searched since inception. Only studies with comparative design reporting the outcome infection rate were included. Seventeen retrospective comparative studies were located comprising 248,541 patients: 16,020 in the DMC group and 232,521 in the CC group. The mean follow-up period was 37.5 ± 42 and 50.2 ± 48.7months for the DMC and CC groups, respectively. The meta-analytical results indicated the following: (a) significantly lesser infections following DMC compared with CC in revision THA (odds ratio (OR) = 0.75 (95% CI = 0.653 to 0.874, P = 0.0002, I2 = 25%); (b) for primary THA and for large-sampled registries, significance was found using only the fixed-effects model estimate; and (c) no significant difference was found for the subgroup of cohort studies. Our results clearly refute the claim that DMC would yield higher rates of infection. On the contrary, the findings demonstrated that the use of DMC reduces the risk of post-operative infection in revision THA and a similar lower infection trend for primary THA when compared with the standard cups.

Outcomes and Risk Factors Associated With 2-Stage Reimplantation Requiring an Interim Spacer Exchange for Periprosthetic Joint Infection

BackgroundPatients undergoing a 2-stage revision for periprosthetic joint infection (PJI) often require a repeat spacer in the interim due to persistent infection. This study aims to report outcomes for patients with repeat spacer exchange and to identify risk factors associated with interim spacer exchange in 2-stage revision arthroplasty. MethodsA total of 256 consecutive 2-stage revisions for chronic infection of total hip arthroplasty and total knee arthroplasty with reimplantation and minimum 2-year follow-up were investigated. An interim spacer exchange was performed in 49 patients (exchange cohort), and these patients were propensity score matched to 196 patients (nonexchange cohort). Multivariate analysis was performed to analyze risk factors for failure of interim spacer exchange. ResultsPatients in the propensity score–matched exchange cohort demonstrated a significantly increased reinfection risk compared to patients without interim spacer exchange (24% vs 15%, P = .03). Patients in the propensity score–matched exchange cohort showed significantly lower postoperative scores for 3 patient-reported outcome measures (PROMs): hip disability and osteoarthritis outcome score physical function (46.0 vs 54.9, P = .01); knee disability and osteoarthritis outcome score physical function (43.1 vs 51.7, P < .01); and patient-reported outcomes measurement information system physical function short form (41.6 vs 47.0, P = .03). Multivariate analysis demonstrated Charles Comorbidity Index (odds ratio, 1.56; P = .01) and the presence of Enterococcus species (odds ratio, 1.43; P = .03) as independent risk factors associated with 2-stage reimplantation requiring an interim spacer exchange for periprosthetic joint infection. ConclusionThis study demonstrates that patients with spacer exchange had a significantly higher risk of reinfection at 2 years of follow-up. Additionally, patients with spacer exchange demonstrated lower postoperative PROM scores and diminished improvement in multiple PROM scores after reimplantation, indicating that an interim spacer exchange in 2-stage revision is associated with worse patient outcomes.

Diagnostic accuracy of MRI with metal artifact reduction for the detection of periprosthetic joint infection and aseptic loosening of total hip arthroplasty

PurposeTo evaluate imaging characteristics obtained from magnetic resonance imaging (MRI) with metal artifact reduction (MAR) to differentiate between periprosthetic joint infection (PJI), aseptic loosening and cases without these pathologies after total hip arthroplasty (THA). MethodsPatients with THA (n = 41; mean age 66.4 ± 9.6 years; 25 women) undergoing 1.5 T MRI with high-bandwidth sequences and view angle tilting followed by revision surgery within 3 months were identified retrospectively. Imaging findings at the metal-bone interface, in the surrounding bone, the soft tissues and lymphadenopathy were assessed by three radiologists in a standardized fashion. Based on clinical and intraoperative findings, patients were categorized in groups with PJI (n = 15), aseptic loosening (n = 15) or without these pathologies (n = 11). Imaging findings were assessed in crosstabs, receiver-operating characteristics and classification and regression trees. ResultsFindings at the acetabular cup were specific for the presence of either PJI or aseptic loosening (specificity>0.765 for all), while findings at the stem were sensitive (sensitivity>0.824 for all except periostitis). To differentiate PJI versus aseptic loosening, soft tissue edema (sensitivity, 0.867/specificity>0.733), abnormalities at both, acetabular and femoral components (0.667/0.933–1.000) and enlarged lymph nodes (0.800/0.867) were accurate. ConclusionStandardized assessment of MR imaging findings in THA patients facilitated the differentiation of PJI and aseptic loosening. This information can be helpful for therapy planning.

The psychological burden of a two-stage exchange of infected total hip and knee arthroplasties.

Infection is one of the most challenging complications after total joint arthroplasties affecting up to 30,000 patients in the US per year. This study investigates the psycho-social burden induced by the two-stage intervention in infected hip or knee replacements. All patients were treated with a two-stage exchange and were assessed at three different timepoints regarding their psychological conditions. Our findings suggest that psychological sequelae after treatment of periprosthetic joint infection are clearly underestimated in the literature and psychological correlates and side effects should be further highlighted during the training process of young surgeons.

Failed Total Hip Arthroplasty: Diagnostic Performance of Conventional MRI Features and Locoregional Lymphadenopathy to Identify Infected Implants.

Very little has been published about the diagnostic performance of MRI in total hip arthroplasty (THA) infection. To determine the diagnostic performance of conventional MRI features and of new lymph nodal indices to identify infection in patients with failed THA. Retrospective. In all, 119 patients (66 females; age 66.9 ± 12.4 years) with failed THA. Metal artifact reduction sequence (MARS) protocol including short tau inversion recovery and turbo spin-echo T1 - and T2 -weighted sequences at 1.5T. Patients underwent pelvis MRI prior to failed THA revision. MRIs were reviewed to identify periprosthetic bone destruction, soft-tissue mass, effusion, synovitis, lamellated synovitis, extracapsular edema, fibrous periprosthetic membrane, bone edema, and extracapsular collection/sinus tract. The number and maximum diameter of inguinal, obturator and iliac lymph nodes of the affected hip were assessed and normalized to those of the unaffected hip to calculate the ratio of nodal size (RNS), ratio of node number (RNN), difference of nodal size (DNS), and difference of node number (DNN). The Mann-Whitney U-and chi-square test were used. Diagnostic performance of indices and odds ratios (OR) were calculated. RNS, RNN, DNS, and DNN indices were significantly different (P = 0.000) between infected and noninfected THA, with accuracies ranging from 84.8% (RNS) and 93.1% (RNN). All other MRI features were significantly more prevalent in infected THA (P ≤ 0.002), except bone destruction, periarticular soft-tissue mass, and fibrous membrane (P ≥ 0.031). Sensitivities ranged from 7.9% (soft-tissue mass) to 76.3% (effusion/bone edema), specificity from 45.7% (bone destruction) to 97.5% (synovitis/lamellated synovitis), accuracy from 49.6% (bone destruction) to 81.5% (synovitis), OR from 0.261 (soft-tissue mass) to 35.550 (synovitis). Conventional MRI features have limited accuracy to differentiate septic and aseptic THA failure. Lymph nodal indices, particularly those related to nodal number, may represent biomarkers of THA infection. 3 TECHNICAL EFFICACY STAGE: 2.

Effect of a Clean Surgical Airflow Layer on the Incidence of Infection in Total Hip Arthroplasty.

The Center for Health Design estimates that more than 30% of surgical site infections are caused by airborne pathogens. A device that creates a localized clean air field directly adjacent to and surrounding the incision site is meant to shield a surgical site from particulate in the operating room. The purpose of this study was to determine whether the routine use of this device would reduce the rate of infection following total hip arthroplasty (THA). The authors conducted a retrospective review of primary THA cases performed with and without the airflow device. Since July 2013, a total of 1093 primary THA cases were performed with the device at the authors' institution. The incidence of wound dehiscence and deep infection was compared with that of 1171 THA cases performed prior to July 2013 without the airflow device. There were no significant differences between the study groups regarding average patient age, sex, body mass index, or diagnosis. In the airflow group, there were 7 (0.64%) deep infections and 5 (0.46%) cases of wound dehiscence that required a return to the operating room for irrigation and wound revision. In the control group, there were 7 (0.60%) cases of deep infection and 4 (0.34%) wound revisions. The groups were not significantly different in the rates of infection (P=1.0) or wound revision (P=.75). Both groups had a very low incidence of infection and wound revision, with rates below 1%. Despite compelling bench data showing a dramatic reduction of particle load in the wound, the use of the airflow device did not reduce the clinical rate of infection over a large number of cases. [Orthopedics. 2020;43(5):e425-e430.].

Characterizing Femoral and Acetabular Bone Loss in Two-Stage Revision Total Hip Arthroplasty for Infection

BackgroundThe process of infection and multiple procedure-related factors in 2-stage exchange arthroplasty may lead to severe bone loss that can complicate subsequent reimplantation. The primary purpose of this study is to quantitatively characterize the extent of bone loss on the femoral and acetabular side prior to reimplantation during 2-stage revision hip arthroplasty for infection. MethodsThis retrospective case series includes 47 patients with planned 2-stage exchange arthroplasty for treatment of infected total hip replacement. Demographic, clinical, and surgical information, and complications during the 2-stage process were collected on all patients. The radiographs of all patients were reviewed prior to first-stage explantation and post-reimplantation or latest follow-up to characterize bone loss using the Paprosky classification systems. ResultsOf the 47 patients with planned 2-stage exchange, 10 patients (21%) were not reimplanted. Following explant and spacer placement, 32 patients (68%) experienced progressive femoral bone loss, and 20 (43%) experienced progressive acetabular bone loss. Patients who experienced progression of both femoral and acetabular bone (14, 30%) had a longer time between resection and reimplantation (164 ± 128 vs 88 ± 26 days, P = .03). A reimplantation time of greater than 90 days was associated with an increased risk of combined bone loss progression (15% vs 53%, P = .01). For patients who underwent reimplantation (79%), increased bone loss led to high rates of diaphyseal femoral fixation (97%) and revision acetabular components (38%). ConclusionIncreased time to reimplantation in 2-stage exchange arthroplasty for prosthetic hip infections is associated with a high rate of acetabular and femoral bone loss, and increased complexity of reimplantation.

A Comparison between the Outcomes of Direct Anterior and Posterior Approaches for Rates of Dislocation and Infection in Primary Total Hip Arthroplasty

Background: Direct anterior hip replacement is a slightly aggressive surgical procedure but potentially widespread. It involves opening on the front of the hip to allow the joint to be substituted by moving muscles aside along their ordinary tissue planes without removing any tendons. Nevertheless, there is diminutive consent concerning the threats and profits of this method compared to the posterior approach (PA) regarding the rates of dislocation and infection. Methods: This research is a prospective study conducted in Erbil city from September 2015 to September 2017 on 57 patients, including 28 females and 29 males, with primary total hip arthroplasty (THA). Twenty-nine patients were enrolled in the direct anterior approach (DAA: First group), and 28 patients were registered in the PA group (PA: Second group). Their age ranged between 49 and 80 years, and the regular follow-up was 12 months for all patients. Results: It was found that using the DAA, there was a significantly (P ≤ 0.05) lower incidence rate of dislocation in patients undergoing THA than the PA. No significant difference in the rates of infection was noticed between both groups. However, slightly shorter operational time and extent of the incision were noticed in the DAA group, and less blood loss was found in the PA group (non-significant). Conclusion: We realized that DAA has a clear advantage over PA regarding the lower incidence in the dislocation risk and without variance in the infection rates.

Do Positive Cultures at Second Stage Re-Implantation Increase the Risk for Reinfection in Two-Stage Exchange for Periprosthetic Joint Infection?

BackgroundIntraoperative cultures are important in the diagnosis and targeted treatment of periprosthetic joint infection (PJI). Positive cultures at reimplantation during a two-stage exchange are discussed as a risk factor for reinfection. The aim of this study is the investigation of the incidence and risk factors for positive cultures during reimplantation. MethodsWe retrospectively identified 204 patients (111 knees, 93 hips) who were treated between 2012 and 2016 for PJI using a two-stage exchange protocol at a median follow-up of 42 months. PJI was diagnosed using the criteria of the musculoskeletal infection society (MSIS) of 2011. All cultural findings from first and second stage surgery were recorded. The primary endpoint was revision for infection. Risk factors for positive cultures and reinfection were analyzed. ResultsDuring reimplantation 25% (51/204) of patients had at least one positive culture, in 19.1% (39/204) only a single culture. Patients with culture-negative infections had a higher risk for positive cultures at reimplantation (HR 2.946 (95% CI 1.247-6.961), P = .014) and patients with infected total hip arthroplasty (THA) (HR 3.547 (95% CI 1.7-7.4), P = .001). Patients with positive cultures during reimplantation had a higher risk for reinfection (HR 2.27 (95% CI 1.181-4.363), P = .014) as well as patients with a single positive culture (HR 2.421 (95% CI 1.139-5.143), P = .021). ConclusionAs positive cultures are common and increase reinfection risk irrespective of their numbers, longer antibiotic therapy following reimplantation can be an option. Single positive cultures in reimplantation surgery should not be considered contamination.

The Effect of Irrigation Fluid on Periprosthetic Joint Infection in Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis.

IntroductionRates of osteoarthritis and total joint arthroplasty (TJA) are on the rise globally. Periprosthetic joint infection (PJI) is the most devastating complication of TJA. A number of different intraoperative interventions have been proposed in an effort to reduce infection rates, including antibiotic cements, local antibiotic powder, and various irrigation solutions. The evidence on the importance of irrigation solutions is limited but has gained prominence recently, including the publication of a large randomized controlled trial (RCT). Thus, the purpose of this study was to evaluate the effectiveness of various irrigation solutions and pressures at reducing the rates of PJI.MethodsA systematic review was performed using the electronic databases MEDLINE, Embase, and Web of Science. All records were screened in duplicate. Data collected included basic study characteristics, the details of the intervention and comparison solutions, if applicable, and rates of superficial and deep infection. A meta-analysis of comparative studies was performed to assess for consistency and potential direction of effect. ResultsA total of ten studies were included, of which one was an RCT, eight were retrospective cohorts, and one was a case series. In total, there were 29,630 TJAs in 29,596 patients. The mean age ranged from 61 to 80 years. Six studies compared povidone-iodine (Betadine®) to normal saline, two studies compared chlorhexidine to saline, one study compared “triple prophylaxis” to standard practice, and one study used gentamicin but had no comparison group. The pooled risk ratio for deep infection in studies using Betadine® compared to saline was 0.62 (95% confidence interval [CI]: 0.33-1.19), while for chlorhexidine it was 0.74 (95%CI: 0.33-1.65).DiscussionCurrent evidence on the relative efficacy of irrigating solutions as prophylaxis for infection following TJA remains inconclusive. Imprecision of estimates vindicates the need for a definitive trial to further inform their use in surgical practice. ConclusionAntiseptic irrigation during TJA with solutions (Betadine®, chlorhexidine) may decrease PJI risk in patients undergoing primary and revision total hip and knee arthroplasties. Wide confidence intervals and heterogeneity among studies, however, render conclusions untrustworthy. Well-conducted RCTs are very much needed to help further investigate this issue.

Characteristics of Antibiotic Prophylaxis and Risk of Surgical Site Infections in Primary Total Hip and Knee Arthroplasty

BackgroundDespite numerous antibiotic prophylaxis options for total hip arthroplasty (THA) and total knee arthroplasty (TKA), an assessment of practice patterns and comparative effectiveness is lacking. We aimed to characterize antibiotic utilization patterns and associations with infection risk and hypothesized differences in infection risk based on regimen. MethodsA retrospective cohort study was performed using data from 436,724 THA and 862,918 TKA (Premier Healthcare Database; 2006-2016). Main exposures were antibiotic type and duration: day of surgery only (day 0) or through postoperative day 1 (day 1). The primary outcome was surgical site infection (SSI) <30 days postoperation. Mixed-effect models measured associations between prophylaxis regimen and SSI as odds ratios (ORs) with 95% confidence intervals (CIs). ResultsSSI prevalence was 0.21% (n = 914) for THA and 0.22% (n = 1914) for TKA. Among THA procedures, the most commonly used antibiotics were cefazolin (74.1%), vancomycin (8.4%), “other” antibiotic combinations (7.1%), vancomycin + cefazolin (5.1%), and clindamycin (3.3%). Here, 51.8% received prophylaxis on day 0 only, whereas 48.2% received prophylaxis through day 1. Similar patterns existed for TKA. Relative to cefazolin, higher SSI odds were seen with vancomycin (OR = 1.36; CI 1.09-1.71) in THA and with vancomycin (OR = 1.29; CI = 1.10-1.52), vancomycin + cefazolin (OR = 1.35; CI = 1.12-1.64), clindamycin (OR = 1.38; CI = 1.11-1.71), and “other” antibiotic combinations (OR = 1.28; CI = 1.07-1.53) in TKA. Prophylaxis duration did not alter SSI odds. Results were corroborated in sensitivity analyses. ConclusionAntibiotic prophylaxis regimens other than cefazolin were associated with increased SSI risk among THA/TKA patients. These findings emphasize a modifiable intervention to mitigate infection risk.

Point/Counterpoint: Nonarticulating vs Articulating Spacers for Resection Arthroplasty of the Knee or Hip

Two-stage exchange arthroplasty remains the gold standard for chronic total knee arthroplasty (TKA) and total hip arthroplasty infections in North America. Cement spacers impregnated with high-dose antibiotics have been successfully used in the interim period of the 2-stage exchange process. A number of spacers have been described; however, this article will focus on articulating spacers. In the presence of an intact extensor mechanism (for TKA), reasonable soft tissue envelope, and adequate bone, articulating antibiotic spacers provide several advantages. These include an infection eradication rate of approximately 90%, higher range of motion after reimplantation, and lower complication rates when compared with nonarticulating spacers. In the appropriate patient, articulating antibiotic spacers are an effective and a safe treatment for infected TKAs and total hip arthroplasties.