Infected Total Joint Arthroplasty Research Articles

The Influence of Patient Sex on Outcomes Following One-Stage and Two-Stage Revision for Periprosthetic Joint Infection in Total Joint Arthroplasty.

Although females have a higher rate of primary total joint arthroplasty (TJA), males have a higher rate of revision. The literature lacks studies examining the relationship between sex and outcomes following single and two-stage exchange for periprosthetic joint infection (PJI). The purpose of this study was to examine if differences exist in outcomes following revision for chronic PJI between sexes. A retrospective review was performed on all patients with an MSIS confirmed PJI who underwent a single or two-stage exchange at our institution from January 2010 to January 2021. Patient demographics, comorbidity characteristics, and outcomes were collected and compared between males and females. The primary outcome variable was disease-free survival at 1 year following definitive revision. Multivariable logistic regression analysis was performed to determine risk factors for failure. Of the 470 patients meeting final eligibility criteria, 250 were male and 226 were female (2 males and 4 females had a joint infection of either the contralateral side or a different joint and were treated as separate records). Of the patients in the cohort, 80% of the males (200/250) and 80% of the females (181/226) were found to be disease-free at 1-year follow-up (p > 0.99). Multivariable logistic regression analysis showed that nicotine use and diabetes, but not sex, were significant predictors of failure. Our study did not find a relationship between sex and outcome of revision for PJI. Further research is required to determine whether differences exist between males and females in the expression of PJI and outcomes following treatment.

Irrigation and Debridement With Chronic Antibiotic Suppression for the Management of Acutely Infected Aseptic Revision Total Joint Arthroplasties

BackgroundMost data on irrigation and debridement with component retention (IDCR) as a treatment for acute periprosthetic joint infections (PJIs) focuses on primary total joint arthroplasties (TJAs). However, the incidence of PJI is greater after revisions. We investigated the outcomes of IDCR with suppressive antibiotic therapy (SAT) following aseptic revision TJAs. MethodsThrough our total joint registry, we identified 45 aseptic revision TJAs (33 hips, 12 knees) performed from 2000 to 2017 that were treated with IDCR for acute PJI. Acute hematogenous PJI was present in 56%. Sixty-four percent of PJIs involved Staphylococcus. All patients were treated with 4 to 6 weeks of intravenous antibiotics with the intention to treat with SAT (89% received SAT). The mean age was 71 years (range, 41 to 90), with 49% being women and a mean body mass index of 30 (range, 16 to 60). The mean follow-up was 7 years (range, 2 to 15). ResultsThe 5-year survivorships free from re-revision for infection and reoperation for infection were 80% and 70%, respectively. Of the 13 reoperations for infection, 46% involved the same species as the initial PJI. The 5-year survivorships free from any revision and any reoperation were 72% and 65%, respectively. The 5-year survivorship free from death was 65%. ConclusionAt 5 years following IDCR, 80% of implants were free from re-revision for infection. As the penalty for implant removal is often high in revision TJAs, IDCR with SAT is a viable option for acute infection after revision TJAs in select patients. Level of EvidenceIV.

Rank-Ordered List of Cost-effective Strategies for Preventing Prosthetic Joint Infection in Total Joint Arthroplasty in an Academic US Hospital.

Although the overall rate of prosthetic joint infection (PJI) is low, it remains a major complication associated with total joint arthroplasty (TJA). PJI represents a significant economic burden to the health care system that is projected to increase commensurate with increasing joint replacement volumes. This review provides a rank-ordered list of cost-effective strategies that are performable intraoperatively and have data supporting their efficacy at preventing PJI after TJA. This study may be helpful in assisting surgeons, ambulatory surgery center owners, and hospital acquisition committees to make reasonable and cost-conscious decisions in the face of changing reimbursement. [Orthopedics. 2023;46(6):327-332.].

How effective is diluted povidone-iodine in preventing periprosthetic joint infection in total joint arthroplasty (TJA)? An updated systematic review and meta-analysis

PurposePeriprosthetic joint infection (PJI) is a serious complication with total joint arthroplasty (TJA), that necessitates reoperation. Pre-closure irrigation with dilute povidone-iodine (PI) is among the preventive measures, but its efficiency is still controversial. As a result, the focus of this systematic review and meta-analysis is on the effect of dilute PI wound irrigation in the prevention of PJI following TJA.MethodsWe systematically reviewed and analyzed articles that compared PI with other agents in terms of PJI rate after TJA, searching Medline, Scopus, Web of science, and Cochrane databases. A number of 13 papers including 63,950 patients in total, were finally considered in qualitative and quantitative assessments. We have also further assessed review articles.ResultsIn comparison with normal saline (NS), PI reduced post-operative infection rate (OR: 0.44; CI 95%: 0.34–0.56). However, there was no difference between PI and chlorhexidine (CHG) (OR: 1.61; CI 95%: 0.83–3.09)) or undetermined comparators (OR: 1.08; CI 95%: 0.67–1.76).ConclusionPI irrigation seems an efficient preventive measure for post-operative PJI and would seem to be the most feasible for TJA protocol.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures

IntroductionDistal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. Methods418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. Results366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DiscussionIn patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

IS POTENTIAL MALNUTRITION ASSOCIATED WITH INCREASED MORBIDITY IN TOTAL HIP AND KNEE ARTHROPLASTY?

Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition.603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin &lt;3.5g/dL, transferrin &lt;200 mg/dL, or TLC &lt;1,500 cells/mm³.Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p&lt;0.05). Pacific Island (p&lt;0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European.This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative nutritional screening and optimisation.

An Alternative Wound Class for Orthopedic Surgery is more Strongly Associated with Risk for Postoperative Infection in Total Joint Arthroplasty than the Current Surgical Wound Classification System

Introduction Surgical site infections (SSI) continue to be a risk associated with surgery. The Centers for Disease Control (CDC) uses surgical wound class (SWC) to predict SSI postoperatively. Prior studies have shown that the current wound class definitions are unreliable for surgical subspecialties. Therefore, an alternative surgical wound classification (ASWC) was created to more accurately reflect risk of SSI following orthopedic procedures. The purpose of this study was to compare the two systems. Methods Seventy patients who developed 90-day SSI following total joint arthroplasty (TJA) were matched 1:1 to patients without postoperative SSI. The SWC was recorded from operative reports. Wounds were then retrospectively reclassified according to the ASWC based on preoperative history from the medical record. The degree of agreement and degree of association with occurrence of SSI was compared between the two systems. Results The proportion of agreement between the systems was poor (41.4%). The current SWC was associated with risk of SSI in both unadjusted (p=0.045) and multivariable analysis (p=0.050). Comparatively, the ASWC demonstrated a stronger association with SSI in both unadjusted (p=0.001) and multivariable analysis (p=0.001). Conclusion The results of this study suggest that the ASWC is more predictive for SSI following TJA than the current SWC definitions for total joint arthroplasty.

Can We Approach a Zero Percent Infection Rate In Total Knee Arthroplasty? A Program To Achieve This Goal With Antimicrobial Agents.

Periprosthetic joint infections (PJIs) are one of the most feared complications in the realm of adult reconstruction due to the substantial morbidity and mortality associated with these cases. Advancements in arthroplasty have been made across a variety of areas of interest including implant surfaces, implant design, material science, etc., but a focus on infection prevention and treatment is of utmost importance. A new technology has been created that targets biofilm and aims to prevent infection in total joint arthroplasty. In this manuscript we aim to describe the benefits of this technology and describe the ideal use in a case scenario format. We believe that with this technology that we can approach the goal of a zero periprosthetic infection rate.

Perioperative Management of Hepatitis C in Patients Undergoing Total Joint Arthroplasty.

A small yet growing subset of total joint arthroplasty (TJA) candidates are diagnosed with the hepatitis C virus (HCV), which is a known risk factor for periprosthetic joint infections. Given the poor outcomes associated with TJA infection, we recommend that candidates with HCV receive treatment prior to elective TJA. Interferon and ribavirin have historically been the standard treatment regimen for the management of HCV; however, adverse events and an inconsistent viral response have limited the efficacy of these therapies. The advent of direct-acting antivirals has resolved many of the issues associated with interferon and ribavirin regimens. Despite the success of direct-acting antivirals, there are still barriers to seeking treatment for TJA candidates with HCV. Many patients are faced with financial burdens, as insurance coverage of direct-acting antiviral therapies is inconsistent and varies by the patient's state of residence and specific treatment regimen. TJA candidates with HCV present health-care providers with a unique set of challenges, often encompassing economic, psychosocial, and complex medical concerns. Multidisciplinary care teams can be beneficial when caring for and optimizing this patient cohort. Management of HCV prior to elective TJA is associated with higher up-front costs but ultimately reduces long-term patient morbidity as well as associated direct and indirect health-care expenditures.

The Effects of Dexamethasone in Diabetic Patients Undergoing Primary Total Joint Arthroplasty.

Dexamethasone reduces postoperative pain and nausea, with no evidence of increased rate of infection in total joint arthroplasty. However, the effects of dexamethasone on diabetic patients undergoing total joint arthroplasty remain relatively unexplored. The purpose of this study was to examine the effects of dexamethasone on postoperative blood glucose levels, prosthetic joint infections (PJIs), and 90-day hospital returns in diabetic patients following total joint arthroplasty. Retrospective analysis was performed on 228 adult patients with a diagnosis of diabetes who underwent primary total joint arthroplasty. Patients were stratified by intraoperative dexamethasone administration. In total, 173 (75.9%) patients received intraoperative dexamethasone, with no differences in demographic variables compared with patients who did not receive dexamethasone. There was no significant difference in PJIs or 90-day hospital returns. Patients who received dexamethasone had significantly increased blood glucose concentration on Postoperative Day 1 and were significantly more likely to have blood glucose levels exceeding 180 g/dl. Although postoperative blood glucose levels were significantly increased, it is unclear what effects, if any, transient hyperglycemia may have on outcomes. The outcomes of this study support perioperative administration of dexamethasone in diabetic patients.

Management of Periprosthetic Hip and Knee Joint Infections With a Known Sinus Tract-A Single-Center Experience.

BackgroundProsthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). A sinus tract communicating with a prosthetic joint is a major criterion defining PJI. Despite this fact, many patients presenting with a draining sinus tract undergo invasive procedures before initiation of two-stage revision arthroplasty. We hypothesized that many patients undergo nondefinitive procedures to treat the sinus tract, rather than undergoing definitive treatment of infection with two-stage revision.MethodsA retrospective review of all cases of two-stage revision arthroplasty at Loyola University Medical Center between January 2004 and May 2018 was performed. Patients with infected TJA and periprosthetic sinus tract were included. Records were queried for laboratory values and prior procedures.ResultsWe identified 160 patients who underwent two-stage revision for infection over the 14-year period. Of the 160 patients, 25 had a documented periprosthetic sinus tract before initiation of definitive revision arthroplasty and were included. Eleven (44.0%) had one or more procedures including interventional radiology drain placement, local wound care, or formal irrigation and debridement before definitive treatment. Forty-five percent of patients that underwent nondefinitive procedures before definitive surgery had either an erythrocyte sedimentation rate or C-reactive protein at normal or near-normal levels.ConclusionMany arthroplasty patients presenting with periprosthetic sinus tracts undergo nondefinitive procedures before definitive treatment. Inherent surgical risks of these procedures can increase the overall morbidity and mortality of these patients. Further effort is needed to educate surgeons regarding management of sinus tracts after TJA.

Perioperative Antibiotic Prophylaxis: Single and 24-Hour Antibiotic Dosages are Equally Effective at Preventing Periprosthetic Joint Infection in Total Joint Arthroplasty

BackgroundPerioperative antibiotic prophylaxis is used to prevent surgical site infection and periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). Secondary to a national shortage of cefazolin, patients at our institution began receiving a single preoperative prophylactic antibiotic dose for primary TJA and no 24-hour postoperative antibiotic prophylaxis. The purpose of the study was to compare the efficacy of single-dose antibiotic use versus 24-hour dosing of prophylactic antibiotics in the prevention of acute PJI and short-term complications after primary TJA. MethodsA retrospective review of 3317 patients undergoing primary TJA performed from January 2015 to December 2019 identified 554 patients who received a single dose of preoperative antibiotic prophylaxis during the antibiotic shortage and 2763 patients who received post-TJA 24-hour antibiotic prophylaxis before the shortage. Patient records were evaluated for acute PJI, superficial infection, 90-day reoperation, and 90-day complications. ResultsThere were no significant differences in patient characteristics between single-dose and 24-hour antibiotic groups. Similarly, there were no significant differences in rates of acute PJI (0.7% vs 0.2%; P = .301), superficial infection (2.4% vs 1.4%; P = .221), 90-day reoperation (2.1% vs 1.1%; P = .155), and 90-day complications (9.9% vs 7.9%; P = .169) between single and 24-hour antibiotic dose. Post hoc power analysis demonstrated adequate sample size, beta = 93%. ConclusionSingle-dose prophylactic antibiotics did not lead to an increased risk of acute PJI or short-term complications after TJA. Our study suggests that administration of a single antibiotic dose may be safely considered in patients undergoing routine primary TJA.

The Expanding Role of Biomarkers in Diagnosing Infection in Total Joint Arthroplasty: A Review of Current Literature.

Consistent diagnosis of periprosthetic infection in total joint arthroplasty continues to elude the orthopedic surgeon because no gold standard test exists. Therefore clinicians must rely on a combination of tests to help aid the diagnosis. The expanding role of biomarkers has shown promising results to more accurately diagnose an infection when combined with clinical suspicion and bacterial culture testing. This paper reviews the diagnostic capabilities of the most current serum and synovial biomarkers as well as next generation sequencing in the setting of periprosthetic joint infection. Future research and high-powered studies will be necessary to determine sensitivity and specificity of each biomarker.

The Impact of Patient-Reported Penicillin Allergy on Risk for Surgical Site Infection in Total Joint Arthroplasty.

Penicillin (PCN) allergy is reported in 10% to 20% of the population; studies show that only 1% to 3% of patients have a true allergy. Most patients reporting a PCN allergy receive second-line antibiotic prophylaxis preoperatively, which raises concerns about antimicrobial efficacy. Studies also suggest that second-line antibiotics may increase the rate of surgical site infection (SSI). In this study we aim to analyze the effect of PCN allergy on antibiotic type prescribed and SSI in our total joint arthroplasty population. A retrospective review of 4,903 primary total hip and total knee arthroplasty performed from January 2015 to June 2017 in a single institution. A detailed chart review was performed to identify reported reactions and antibiotic prescribed. Seven hundred ninety-six patients (16.2%) reported a PCN allergy; the reactions were classified into three tiers. Six hundred fifteen patients (12.5%) reported an IgE-mediated allergy, hypersensitivity, or a possible allergy; 89 (1.8%) reported an adverse effect; and 92 (1.9%) had an unknown reaction. Patients reporting a PCN allergy were less likely to receive cefazolin (94.9 versus 6.9%; P < 0.001) and more likely to receive clindamycin (1.1 versus 80.7%; P < 0.001) or vancomycin (4.0 versus 12.4%; P < 0.001). There was no difference in infection rate by reported PCN allergy (0.6 versus 0.4%; P = 0.473) or antibiotic prescribed (0.5 versus 0.6%; P = 0.4817). No patient with a PCN allergy and given cefazolin experienced a reaction; based on reported reactions, most patients with a PCN allergy can safely receive first-line antibiotic therapy. In this population, PCN allergy and second-line antibiotic therapy did not influence the rate of SSI.

Perioperative Management of the Penicillin-Allergic Patient

AN ESTIMATED 32 MILLION AMERICANS have a documented penicillin allergy in their medical record, which equates to approximately 10% of the population in the United States. 1 Evaluation and diagnosis of penicillin allergy for healthcare professionals: is it really a penicillin allergy. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP), 2017https://www.cdc.gov/antibiotic-use/community/for-hcp/Penicillin-Allergy.htmlDate accessed: August 1, 2019 Google Scholar Yet more than 97% are not at risk for an acute allergic reaction to penicillin. 2 Fox S. Park M.A. Penicillin skin testing in the evaluation and management of penicillin allergy. Ann Allergy Asthma Immunol. 2011; 106: 1-7 Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar Many agents recommended as first-line therapy for surgical infection prophylaxis are among the β-lactam pharmaceutical class, such as penicillin, aminopenicillins, cephalosporins, monobactams, and carbapenems (Table 1). 3 Bratzler D.W. Dellinger E.P. Olsen K.M. et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70: 195-283 Crossref PubMed Scopus (1275) Google Scholar Studies indicate that 76% to 93% of patients who report a penicillin allergy receive second-line antibiotics for surgical infection prophylaxis. 4 Stone A.H. Kelmer G. MacDonald J.H. Clance M.R. King P.J. The impact of patient-reported penicillin allergy on risk for surgical site infection in total joint arthroplasty. J Am Acad Orthop Surg. 2019; ([Epub ahead of print])https://doi.org/10.5435/JAAOS-D-18-00709 Crossref Scopus (22) Google Scholar , 5 Blumenthal K.G. Ryan E.E. Li Y. Lee H. Kuhlen J.L. Shenoy E.S. The impact of a reported penicillin allergy on surgical site infection risk. Clin Infect Dis. 2018; 66: 329-336 Crossref PubMed Scopus (204) Google Scholar , 6 Beltran R.J. Kako H. Chovanec T. Ramesh A. Bissonnette B. Tobias J.D. Penicillin allergy and surgical prophylaxis: cephalosporin cross-reactivity risk in a pediatric tertiary care center. J Pediatr Surg. 2015; 50: 856-859 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Table 1β-Lactam Antimicrobials in the Surgical Prophylaxis Guidelines 3 Bratzler D.W. Dellinger E.P. Olsen K.M. et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70: 195-283 Crossref PubMed Scopus (1275) Google Scholar Penicillin Derivatives Cephalosporins Monobactam Carbapenem Ampicillin Cefazolin Aztreonam Ertapenem Ampicillin-sulbactam Cefotetan Piperacillin-tazobactam Cefoxitin Cefotaxime Ceftriaxone Cefepime Open table in a new tab Rachel C. Wolfe, PharmD, MHA, BCCCP, Pharmacy Department, Barnes-Jewish Hospital, St. Louis, MO

Mini Review on the Impact of Mobile Parts' Exchange During the DAIR Procedure (Debridement, Antibiotics, Irrigation, Retention) for Infected Total Joint Arthroplasties

A prosthetic joint infection (PJI) requires a combined approach (infectiology and surgery). The therapeutic DAIR approach (debridement, antibiotics, irrigation, and retention) is an option for acute and stable PJI yielding remission incidences that oscillate between 70% and 90%; in a literature mostly composed of retrospective single-center trials. DAIR can be performed with or without mobile part’s exchange during debridement. Scientific data proving the necessity of mobile part exchanges (by leaving other infected components in situ) remain scarce. In this narrative mini review, we evaluate the existing literature that analyses the benefit of exchanging mobile parts with at least ten own cases. We moreover discuss the optimal duration of concomitant targeted systemic antibiotic therapy and reveal some insights in the surgical difficulties in performing DAIR. Our conclusion tends to favor of the mobile part’s exchange whenever feasible.

Effect of Preoperative Dental Extraction on Postoperative Complications After Total Joint Arthroplasty

BackgroundPoor dental hygiene has historically been considered a potential risk factor for infection in total joint arthroplasty (TJA), which has resulted in the common practice of requiring preoperative dental clearance and often results in dental extractions. However, the association between dental pathology and periprosthetic joint infection (PJI) has recently been called into question. MethodsA consecutive series of 2457 primary total hip and total knee arthroplasties were retrospectively reviewed. Documented dental evaluation was found in 1944 (79.1%) procedures, 223 (11.5%) of which had extraction of at least 1 tooth. No documented dental evaluation was found in 369 (15.0%) patients. ResultsThe overall complication rate was 3.87% with an overall PJI rate of 1.51%. There was no statistically significant association between a complication and procedure type, sex, preoperative dental evaluation or extraction, diabetes status, immunosuppression, malnutrition, or age. However, our sample demonstrated a higher complication rate among patients undergoing dental extraction as well as for those with diabetes and immunosuppressed patients. ConclusionOur findings suggest that routine formal dental clearance for all TJA patients may not be necessary. Additionally, patients with poor oral hygiene may not have elevated risk of postoperative PJI, and preoperative tooth extraction may represent an unnecessary step for patients undergoing elective TJA.

The Benefice of Mobile Parts' Exchange in the Management of Infected Total Joint Arthroplasties with Prosthesis Retention (DAIR Procedure).

Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective cohort in PJIs treated with DAIR. Results: We included 112 PJIs (69 total hip arthroplasties, 9 medullary hip prostheses, 41 total knee arthroplasties, and 1 total shoulder arthroplasty) in 112 patients (median age 75 years, 52 females (46%), 31 (28%) immune-suppressed) and performed a DAIR procedure in all cases—48 (43%) with exchange of mobile parts and 64 without. After a median follow-up of 3.3 years, 94 patients (84%) remained in remission. In multivariate Cox regression analysis, remission was unrelated to PJI localization, pathogens, number of surgical lavages, duration of total antibiotic treatment or intravenous therapy, choice of antibiotic agents, immune-suppression, or age. In contrast, the exchange of mobile parts was protective (hazard ratio 1.9; 95% confidence interval 1.2–2.9). Conclusions: In our retrospective single-center cohort, changing mobile parts of PJI during the DAIR approach almost doubled the probability for long-term remission.

Comparison between the Staphylococci aureus and coagulase-negative staphylococci infected total joint arthroplasty treated by two-stage revision: A retrospective study with two year minimum follow-up

BackgroundStaphylococcus species are major pathogens of peri-prosthetic joint infection (PJI). Coagulase-positive staphylococci and coagulase-negative staphylococci have different intrinsic virulences. However, few studies have specifically compared the clinical manifestations and two-stage revision outcomes of PJI caused by these two species. MethodsWe retrospectively collected 260 arthroplasty patients who underwent a two-stage revision because of PJI from January 2003 to June 2015 in our institute because of PJI. Sixty-four patients (36 hips and 28 knees) and 23 patients (13 hips and 10 knees) were infected by coagulase-negative staphylococci (CoNS) and SA, respectively. ResultsThe preoperative mean ESR value of the SA group was higher than that of the CoNS group (median, 60.9 VS 35.9; P < 0.001). Seventeen (73.9%) of the 23 SA infected patients had a sinus tract, while only 12 (18.8%) of the 64 CoNS-infected patients had this symptom (73.9% VS 18.8%; P < 0.001). At the time of follow-up, 58 (90.6%) of the 64 CoNS-infected patients had successfully controlled the infection. In the SA group, 20 (87.0%) patients ultimately acquired successful control (90.6% VS 87.0%; P = 0.923). Surgical history was identified as a potential risk factor (OR = 6.2, 95%CI 1.17–32.4) for prognosis when potential covariates were adjusted. ConclusionsSA infection has a higher ESR value and a more frequent occurrence of sinus tract. The infection control rate of the two-stage revision protocol was close to 90% for both SA and CoNS species, and there is no statistically significant difference in the eradication rate of infection between the SA and CoNS groups. Surgical history may be a good predictor of failure for PJI patients treated with two-stage revision.

Antiseptics Commonly Used in Total Joint Arthroplasty Interact and May Form Toxic Products

BackgroundMultiple antiseptics have been described for use in total joint arthroplasty infection, and the use of multiple antiseptic solutions during a single operation has been described. Our clinical experience is that chlorhexidine (CHX) and Dakin's solution (NaOCl) interact and form a precipitate. The purpose of this study is to determine whether this reaction could be replicated in a laboratory setting, and to determine if other commonly used antiseptics also visibly react when mixed. MethodsFour percent chlorhexidine gluconate (CHX), 0.5% sodium hypochlorite (NaOCl), 3% hydrogen peroxide (H2O2), and 10% povidone-iodine (BTD) solutions were obtained and all possible combinations were mixed. Any visible reactions were noted and recorded, and a literature search was performed to characterize the reaction and products. ResultsCHX and NaOCl, CHX and H2O2, and CHX and BTD reacted instantly, forming a precipitate. NaOCl and H2O2 reacted to produce a gas. NaOCl and BTD reacted and produced a color change. The literature review revealed that at least 2 of the reactions tested (CHX + NaOCl and NaOCl + H2O2) could result in byproducts toxic to humans. ConclusionSurgeons must be aware of these interactions when using antiseptic solutions during procedures. Caution should be used combining or mixing antiseptics, and we recommend against concomitant introduction in a surgical wound.