Management Of Prosthetic Joint Infection Research Articles

Antibiotic-loaded cement in total joint arthroplasty: a comprehensive review.

This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use.

The Safety of Glycopeptide-Impregnated Calcium Sulphate Following Debridement, Antibiotics and Implant Retention (DAIR) for Infected Total Knee Replacement.

Background and objective The impact of prosthetic joint infection (PJI) stretches far beyond the physical nature of the disease. It can result in psychological and social consequences, with significant morbidity and mortality for patients. Calcium sulphate-based delivery agents are effective in the management of PJI, yet with associated risks of systemic adverse events. This study aims to evaluate the risk of systemic adverse events when using calcium-sulphate-based local antibiotic delivery agents in the management of PJIs. Methodology We identified 43 patients who underwent debridement, antibiotics and implant retention (DAIR) for infected total knee arthroplasty (TKA) between 2008 and 2014. Patients in the control groupunderwent conventional intravenous and then oral antibiotic administration, while those in the intervention groupunderwent additional local antibiotic therapy via a calcium sulphate alpha hemihydrate matrix. Case notes and laboratory results data were compiled to establish the safety and efficacy of local glycopeptide delivery. Results Serum vancomycin levels were within the safe therapeutic range for all patients in the intervention group with no difference in serum assays between treatment groups (intervention 7.7 mg/L; control 8.0 mg/L; P = 0.85). Renal function for the study cohort improved at every time point post-operatively when referenced against pre-operative renal function (P < 0.05). There was no difference in renal function between intervention and control groups on day 1, one week, six weeks or 12 weeks post-operatively (P = 0.78, 0.89, 0.20 and 0.50). Conclusions Local glycopeptide delivery via a calcium sulphate alpha hemihydrate matrix did not result in systemic adverse consequences specifically not raising the systemic level of glycopeptide, nor reducing renal function. Implications for future research Although demonstrates a safety profile and potential therapeutic benefit, the long-term efficacy of this approach needs to be established. Importantly, selection bias may contribute to masking clinically significant differences in post-operative outcomes.

Addressing important evidence gaps in the management of prosthetic joint infection: clinician attitudes and equipoise.

Addressing important evidence gaps in the management of prosthetic joint infection: clinician attitudes and equipoise.

Risk Factors and Management of Prosthetic Joint Infections in Megaprostheses-A Review of the Literature.

Prosthetic joint infection (PJI) is the most common mode of failure of megaprostheses, yet the literature on the topic is scarce, and studies report conflicting data regarding the optimal treatment strategy. Patients with megaprostheses PJI are often immunosuppressed, and surgeons must balance the trade-off between treatment efficacy and morbidity associated with the surgery aiming for infection eradication. Our review on megaprostheses PJI focuses on two axes: (1) risk factors and preventative strategies; and (2) surgical strategies to manage this condition. Risk factors were classified as either unmodifiable or modifiable. Attempts to decrease the risk of PJI should target the latter group. Strategies to prevent PJI include the use of silver-coated implants, timely discontinuation of perioperative antibiotic prophylaxis, and adequate soft tissue coverage to diminish the amount of dead space. Regarding surgical treatment, main strategies include debridement, antibiotics, implant retention (DAIR), DAIR with modular component exchange, stem retention (DAIR plus), one-stage, and two-stage revision. Two-stage revision is the "gold standard" for PJI in conventional implants; however, its success hinges on adequate soft tissue coverage and willingness of patients to tolerate a spacer for a minimum of 6 weeks. DAIR plus and one-stage revisions may be appropriate for a select group of patients who cannot endure the morbidity of two surgeries. Moreover, whenever DAIR is considered, exchange of the modular components should be performed (DAIR plus). Due to the low volume of megaprostheses implanted, studies assessing PJI should be conducted in a multi-institutional fashion. This would allow for more meaningful comparison of groups, with sufficient statistical power. Level of evidence: IV.

Controversies in the microbiological diagnosis and treatment of bone and joint infections

Recently, bone and joint infections such as fracture-related infection (FRI) and prosthetic joint infections (PJI) have been defined for clinical and research purposes. National and international guidelines are being produced to guide clinicians towards what is considered best practice. However, much of what we do regarding the microbiological diagnosis and management of orthopaedic infection is based on expert opinion, rather than evidence-based medicine. This is largely because, prior to the publication of the clinical definitions of orthopaedic infection, studies included a heterogeneous population making comparisons between them difficult. More recently the publication of large clinical trials in the antimicrobial management of orthopaedic infection has demonstrated that such clinical research is possible, and can both challenge the existing dogma in this field and lead to universal changes in clinical practice. There is robust evidence for microbiological sampling techniques and their interpretation in diagnosis of orthopaedic infection, as well as the choice of empiric broad-spectrum antibiotics and the non-inferiority of oral versus intravenous systemic antibiotics. For other elements of the diagnosis and management of orthopaedic infection this is not the case. For example, there are limited or no data to support recommendations regarding time off antibiotics prior to microbiological sampling, systemic antibiotic duration, when to do a joint aspirate in PJI revisions or the timing of definitive joint implantation in the two-stage management of PJI. In summary, this review highlights what is currently considered best practice within the field of orthopaedic infection and discusses both the evidence behind it and where there is controversy or where further research is warranted.

Investigation of the effect of rifampicin resistance and risk factors on recovery rates after DAIR procedure in patients with prosthetic joint infection

BackgroundRifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favourable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing debridement, antibiotics and implant retention (DAIR).MethodsWe reviewed medical records and microbiology reports of 67 patients (37 males and 30 females) undergoing DAIR due to PJI between 2014 and 2021. Patient-related factors, co-morbidities and microbiological reports were collected and reviewed. Forty-four patients had hip, 21 had knee, 1 had shoulder and 1 had elbow joint infection. Obtained data were statistically analysed with a logistic regression model.ResultsRifampicin-sensitive organism was isolated in 47 cases. Recovery rate was 72.3% in the sensitive and 76.9% in the resistant group. We found no significant effect of rifampicin resistance on the probability of recovery. Age and diabetes mellitus showed negative clinical impact on recovery. Staphylococcus aureus and coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (66.6% of the isolates) and Gram-negative rods in the resistant group (65.2%).ConclusionsBased on our results, higher age and diabetes mellitus may have a clinically relevant negative impact on clinical outcome, however, this effect was not statistically significant. This may be due to the limited number of patients included in this study. We observed no clinically relevant effect of rifampicin-resistance, sex and body mass index (BMI) on recovery rates among patients undergoing DAIR due to PJI.

Multidisciplinary team meetings in prosthetic joint infection management: A qualitative study.

Prosthetic joint infections (PJIs) cause substantial morbidity to patients and are extremely challenging for clinicians. Their management can include multiple operations, antibiotics, and prolonged hospital admissions. Multidisciplinary team meetings (MDTM) are increasingly used for collaborative decision-making around the management of PJIs, but thus far there has been no examination of the role of MDTM in decisions and management. This study aimed to examine interactions in a PJI MDTM to identify the dynamics in decision-making, and inter-specialty relationships more broadly. Twelve MDTMs over 7 months at an Australian tertiary referral hospital were video recorded, transcribed, and thematic analysis was performed. Thematic analysis revealed four key areas of collaborative discussion 1. Achieving Inter-specialty Balance: The role of the multidisciplinary team discussion in providing balance between specialty views, and traversing the barriers between specialty interactions. 2. Negotiating Grey zones: there was frequent discussion of the limits of tests, interpretation of symptoms, and the limits of proposed operative strategies, and the resultant tensions of balancing ideal care vs pragmatic decision-making, and divergent goals of care. 3. Tailoring Treatment: identification of individual patient factors (both physiological and behavioural) and risks into collaborative decision-making. 4. Affording Failure: creating affordances in communication to openly discuss 'failure' to eliminate infection and likely negative outcomes. MDTM in the management of prosthetic joint infections serve multiple functions including: achieving interdisciplinary balance; effective grey zone management, tailoring reconfigured care; and most critically, recognition of 'failure' to eliminate infection, a communicative affordance most likely leading to better care.

Description of reinfection of joint prosthesis after 2-stage replacement (infection of the 2nd stage prosthesis): A multicenter study

IntroductionTwo-stage exchange is the gold standard in the surgical management of prosthetic joint infection (PJI). However, perioperative reinfections (RePJI) can occur to newly inserted prosthesis, which highlights the importance of an adequate antibiotic prophylaxis, although there is scarce evidence in this field. Our objective was to evaluate the characteristics of RePJI, its prognosis and the antibiotic prophylaxis that is commonly used in second-stage surgery. MethodsMulticentric retrospective observational study in Spanish hospitals including patients with RePJI between 2009 and 2018. ResultsWe included 92 patients with RePJI from 12 hospitals. The most frequent isolated microorganism was Staphylococcus epidermidis in 35 cases (38.5%); 61.1% of staphylococci were methiciliin-resistant. In 12 cases (13%), the same microoganism causing the primary PJI was isolated in RePJI. When comparing with the microbiology of primary PJI, there were more cases caused by Gram-negative bacteria (the most frequent was Pseudomonas spp.) and less by Gram-positive bacteria. Failure occured in 69 cases (75%). There were 43 different courses of antibiotic prophylaxis after the second-stage surgery; the most frequent was a unique preoperative cefazolin dose, but most patients received prophylaxis before and after the second-stage surgery (61 cases). ConclusionsThe most frequent microorganisms in RePJI are coagulase-negative staphylococci, although Gram-negative bacteria, especially Pseudomonas spp. are also common. There is a significant heterogeneity in antibiotic prophylaxis for a second-stage surgery. ReIPJI treatment has a high failure rate.

Caracterización de la reinfección de prótesis articular tras recambio en 2 tiempos (infección de la prótesis del 2.o tiempo). Un estudio multicéntrico

IntroductionTwo-stage exchange is the gold standard in the surgical management of prosthetic joint infection (PJI). However, perioperative reinfections (RePJI) can occur to newly inserted prosthesis, which highlights the importance of an adequate antibiotic prophylaxis, although there is scarce evidence in this field. Our objective was to evaluate the characteristics of RePJI, its prognosis and the antibiotic prophylaxis that is commonly used in second-stage surgery. MethodsMulticentric retrospective observational study in Spanish hospitals including patients with RePJI between 2009 and 2018. ResultsWe included 92 patients with RePJI from 12 hospitals. The most frequent isolated microorganism was Staphylococcus epidermidis in 35 cases (38.5%); 61.1% of staphylococci were methiciliin-resistant. In 12 cases (13%), the same microorganism causing the primary PJI was isolated in RePJI. When comparing with the microbiology of primary PJI, there were more cases caused by Gram-negative bacteria (the most frequent was Pseudomonas spp.) and less by Gram-positive bacteria. Failure occurred in 69 cases (75%). There were 43 different courses of antibiotic prophylaxis after the second-stage surgery; the most frequent was a unique preoperative cefazolin dose, but most patients received prophylaxis before and after the second-stage surgery (61 cases). ConclusionsThe most frequent microorganisms in RePJI are coagulase-negative staphylococci, although Gram-negative bacteria, especially Pseudomonas spp. are also common. There is a significant heterogeneity in antibiotic prophylaxis for a second-stage surgery. ReIPJI treatment has a high failure rate.

The rate and management of prosthetic joint infection in the low-income setting: a cross-sectional study.

Using data from the ECAR, for over 10 years, and surveying six high-volume arthroplasty surgeons, we reviewed the infection rate, common organisms, antibiotics used, and how the revision surgeries were done. The total number of patients included in this study was 210 infection cases out of 5216 THA and TKA. Out of the 5216 joint replacement surgeries, the rate of all infections in THA and TKA was 4.03% (4.73 and 2.94%, respectively). The rate of infections requiring staged revision surgeries was 2.24 and 1.71% (2.03% in total) in the THA and TKA groups, respectively. The most encountered organism was Staphylococcus aureus. The common antibiotics used were vancomycin and a combination of cefoperazone and sulbactam. From this study, we conclude that THA was associated with a higher rate of PJI, surgeons' use of antibiotics for a relatively long period, and the rate of PJI in our setting is relatively higher than what is reported in developed countries but lower in other low-income settings. We believe that with improved operating theater design and infection control education, infection rates will decrease significantly. Finally, we acknowledge the need for a national arthroplasty registry that can help in documentation and improving patient outcomes.

Combination d-Amino Acid and Photothermal Hydrogel for the Treatment of Prosthetic Joint Infections.

Prosthetic joint infection (PJI) is a devastating complication requiring surgical intervention and prolonged antimicrobial treatment. The prevalence of PJI is on the rise, with an average incidence of 60,000 cases per year and a projected annual cost of $1.85 billion in the US. The underlying pathogenesis of PJI involves the formation of bacterial biofilms that protect the pathogen from the host immune response and antibiotics, making it difficult to eradicate such infections. Biofilms on implants are also resistant to mechanical brushing/scrubbing methods of removal. Since the removal of biofilms is currently only achievable by the replacement of the prosthesis, therapies aimed at eradicating biofilms while enabling retention of implants will revolutionize the management of PJIs. To address severe complications associated with biofilm-related infections on implants, we have developed a combination treatment that is based on a hydrogel nanocomposite system, containing d-amino acids (d-AAs) and gold nanorods, which can be delivered and transforms from a solution to a gel state at physiological temperature for sustained release of d-AAs and light-activated thermal treatment of infected sites. Using this two-step approach to utilize a near-infrared light-activated hydrogel nanocomposite system for thermal treatment, following initial disruption with d-AAs, we were able to successfully demonstrate in vitro the total eradication of mature Staphylococcus aureus biofilms grown on three-dimensional printed Ti-6Al-4V alloy implants. Using a combination of cell assays, computer-aided scanning electron microscopy analyses, and confocal microscopy imaging of the biofilm matrix, we could show 100% eradication of the biofilms using our combination treatment. In contrast, we were only able to see 25% eradication of the biofilms using the debridement, antibiotics, and implant retention method. Moreover, our hydrogel nanocomposite-based treatment approach is adaptable in the clinical setting and capable of combating chronic infections brought about by biofilms on medical implants.

MANAGEMENT OF PERIPROSTHETIC JOINT INFECTION FOLLOWING TOTAL JOINT ARTHROPLASTY: EXPERIENCE FROM A RURAL CENTRE

Prosthetic joint infection (PJI) remains one of the most challenging complications to manage following total joint arthroplasty (TJA). There is a paucity of published data on the management of PJI in smaller, rural hospital settings. In this study, we investigate [1] the success rate of surgical management for PJI following TJA and [2] the microbiology of infecting organisms in this unique geographical environment.We performed a retrospective single-centre study at a rural hospital (Southland Hospital, Invercargill, New Zealand) over a 3-year period (2019 to 2022). All patients presenting with a first episode of PJI fulfilling Musculoskeletal Infection Society criteria after hip or knee arthroplasty were included. All patients had a minimum follow up of 6 months. Treatment success was defined eradication of infection.Twenty-one cases (14 hips and 7 knees) were identified. These were managed with Debridement, antibiotics, and implant retention (DAIR) procedure (n=14, 67%), single-stage revision (n=6, 29%), or long-term suppressive antibiotics (n=1, 4%). Of the DAIR patients, infection recurred in 50% and underwent subsequent revision. Of the single-stage revision patients, 17% failed and underwent subsequent revision. The overall success rate was 90%. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most isolated pathogen (57%,) with no methicillin-resistance Staphylococcus aureus (MRSA) identified. Overall, 90% of infecting organisms were cefazolin sensitive.These results suggest that management of PJI is a safe and viable treatment option when performed in a rural hospital setting, with comparable treatment success rates to urban centres. The incidence of MRSA is low in this setting. Rates of antibiotic resistance were relatively low and most organisms were sensitive to cefazolin, the routine antibiotic used in prophylaxis.

AUSTRALIAN CAPITAL TERRITORY PROSTHETIC JOINT INFECTION DATABASE: ANALYSIS OF THE FIRST 100 PATIENTS

Prosthetic joint infections (PJI) are one of the most devastating complications of joint replacement surgery. They are associated with significant patient morbidity and carry a significant economic cost to treat. The management of PJI varies from antibiotic suppression, debridement, antibiotics, and implant retention (DAIR) procedures through to single/multiple stage revision procedures. Concerns have been raised recently in relation to the rising number of revision arthroplasty procedures that are being undertaken in relation to infection. This database aims to collect data on all PJIs that have been managed in the Australian Capital Territory (ACT) region. This will allow us to investigate the microbial trends, outcomes of surgical intervention and patient outcomes within our local population.This database will incorporate diagnostic, demographic, microbiological and treatment information in relation to local PJI cases. The data will be collated from the local infectious diseases database, hospital medical records, and where available the Australian Orthopaedic Association National Joint Replacement Registry Data.The first 100 cases of PJI were assessed. 76% were defined as being acute. 56% of the patients received antibiotics prior to their diagnosis however only 3% were culture negative. 89% were monomicrobial and 11% polymicrobial. The intended management strategy was a DAIR in 38% of patients and a 2-stage revision in 12% of cases. The intended management strategy was successful in 46% of the patients.The ACT is uniquely placed to analyze and create a local PJI database. This will allow us to guide further treatment and local guidelines in terms of management of these complex patients.

Simple and cost-effective way to make mobile antibiotic cement spacer: hand-made silicone mold

Background: Two-stage exchange arthroplasty is considered the most common approach for the management of prosthetic joint infections. There has been plentiful evidence to support the superiority of the mobile spacers over the static ones. Unfortunately, articulating options are not available in our low-resource environment, which motivated us to come up with an affordable way to create a mobile cement spacer. After experimenting with a variety of materials and producing methods, we realized that silicone is a favorable material for mold building and established a simple process of making a handmade silicone mold. We demonstrate the clinical outcomes of three prosthetic joint infections by using these spacers in the hope of spreading the idea to our colleagues who work in the circumstances of a developing country. Construction of the spacer molds: The molds, consisting of two parts, were shaped by using high viscosity addition silicone (elite HD+ putty soft, Zhermack SpA, Italy) as material, and previously removed implants as template. They were sterilized using ethylene oxide treatment before being ready for casting antibiotic-loaded bone cement spacer. Case report: Three cases of prosthetic infection were treated with two-stage revision, using antibiotic-impregnated cement spacer cast in hand-made silicone molds. We sought to determine intraoperative complications, postoperative range of motion, and functional scores. All the patients were regularly followed up to identify fractures or dislocation of the spacer, and reinfection. Results: At the end of the follow-up, all three patients had the infection eradicated. The three patients could sit comfortably with bent knees, walk with partial weight-bearing, and achieve 75–80 degrees of knee flexion in the first week after surgery. Follow-up X-rays revealed no fractures or dislocation in any of the spacers. Conclusion: Silicone molds offer a simple and cost-effective alternative to costly commercial products in producing articulating spacers. Treating infected joints arthroplasty with these spacers allows for early motion and partial weight bearing and improves patient satisfaction and life quality before reimplantation without significant complications.

985. Practice Patterns of Antimicrobial Suppression Therapy in Total Knee Arthroplasty Infections

Abstract Background There are no current established guidelines for the role of antimicrobial suppression therapy in management of prosthetic joint infection (PJI). In 2013, the IDSA provided initial treatment guidelines for PJI but did not address suppressive therapy. The guidelines do not address suppressive therapy beyond the initial 4-6 weeks for non-staphylococcal infections nor do they address suppressive therapy after 3-6 months of treatment for Staphylococcal infections. Practitioners must delicately balance the risk of PJI recurrence and the negative effects of continued antibiotic therapy including toxicity and resistance. In this study, we surveyed Infectious Disease providers to better understand their antimicrobial suppression practice patterns in different clinical scenarios. Methods We surveyed Infectious Disease providers across the United States from April 2022 to May 2022. We received 78 unique response from 31 different states. Basic demographic data was obtained. Providers presented six multiple choice clinical scenarios and were asked if they would start suppressive therapy and the duration of suppressive therapy. Results The preliminary data revealed that practice patterns vary greatly amongst providers in the management of antibiotic suppressive therapy in PJI. Of the 6 scenarios, only half had greater than 50% consensus (50.6%, 51.3% and 70.1%). Scenario 1 involved a patient who underwent a single stage revision. It was of particular interest as 51.3% of providers indicated they would stop antimicrobial therapy and 48.7% indicated they would extend antimicrobial therapy with 25.6% electing for lifelong suppressive therapy. Conclusion Practice patterns for antimicrobial suppression therapy in knee PJI varies significantly among providers. Even with IDSA guidelines addressing Staphylococcal PJI, the practice patterns among infectious diseases providers still varied greatly especially with regards to single stage revisions. Additional randomized controlled trials examining the best way to manage antimicrobial suppression in PJI would be helpful, and would allow for development of evidence-based guidelines. We also plan to survey orthopedic surgeons using the same clinical scenarios to see if there is a difference in management styles. Disclosures All Authors: No reported disclosures.

Rates and Predictors of Treatment Failure in Staphylococcus aureus Prosthetic Joint Infections According to Different Management Strategies: A Multinational Cohort Study-The ARTHR-IS Study Group.

Guidelines have improved the management of prosthetic joint infections (PJI). However, it is necessary to reassess the incidence and risk factors for treatment failure (TF) of Staphylococcusaureus PJI (SA-PJI) including functional loss, which has so far been neglected as an outcome. A retrospective cohort study of SA-PJI was performed in 19 European hospitals between 2014 and 2016. The outcome variable was TF, including related mortality, clinical failure and functional loss both after the initial surgical procedure and after all procedures at 18months. Predictors of TF were identified by logistic regression. Landmark analysis was used to avoid immortal time bias with rifampicin when debridement, antibiotics and implant retention (DAIR) was performed. One hundred twenty cases of SA-PJI were included. TF rates after the first and all surgical procedures performed were 32.8% and 24.2%, respectively. After all procedures, functional loss was 6.0% for DAIR and 17.2% for prosthesis removal. Variables independently associated with TF for the first procedure were Charlson ≥ 2, haemoglobin < 10g/dL, bacteraemia, polymicrobial infection and additional debridement(s). For DAIR, TF was also associated with a body mass index (BMI) > 30kg/m2 and delay of DAIR, while rifampicin use was protective. For all procedures, the variables associated with TF were haemoglobin < 10g/dL, hip fracture and additional joint surgery not related to persistent infection. TF remains common in SA-PJI. Functional loss accounted for a substantial proportion of treatment failures, particularly after prosthesis removal. Use of rifampicin after DAIR was associated with a protective effect. Among the risk factors identified, anaemia and obesity have not frequently been reported in previous studies. This study is registered at clinicaltrials.gov, registration no. NCT03826108.

Is 2-Stage Septic Revision Worth the Money? A Cost-Utility Analysis of a 1-Stage Versus 2-Stage Septic Revision of Total Knee Arthroplasty

BackgroundTwo-stage exchange arthroplasty remains the gold standard for the management of prosthetic joint infection (PJI) of the knee, but several studies have demonstrated that 1-stage exchange is as effective as 2-stage exchange. This study aimed to support decision-making via an economic evaluation of 1-stage compared to 2-stage exchange for total knee arthroplasty septic revision in patients who did not have compelling indication PJI (ie, Methicillin-resistant Staphylococcus aureus, multiorganism, systemic sepsis, comorbidities, culture negative, resistant organism, and immunocompromised) to undergo a 2-stage exchange. MethodsA cost-utility analysis was performed using a Markov cohort model from the health care provider perspective using Australia data. One-stage septic knee revisions were compared with 2-stage exchange procedures for chronic PJI using a patient-lifetime horizon. Health outcomes were expressed as quality-adjusted life-years (QALY), whereas costs were presented in 2020 Australian dollars. Sensitivity analyses, population expected values of perfect information, and the perfect information for parameters (EVPPI) were assessed to estimate the opportunity costs surrounding the decision made at a willingness-to-pay threshold of $50,000 per QALY. ResultsThe incremental cost-effectiveness ratio of 2-stage exchange compared with 1-stage exchange was $231,000 per QALY, with 98.5% of the probabilistic sensitivity simulations above the willingness-to-pay threshold. The population expected value of perfect information was $882,000, whereas the expected value of perfect information for parameters for the “cost parameters” was $207,000. ConclusionThe adoption of 1-stage septic knee revision is the optimal choice for patients who have a PJI and who do not have a compelling need for a 2-stage exchange arthroplasty. One-stage exchange for PJI should be advocated in patients who meet the eligibility criteria.

173 Debridement, Antibiotics and Implant Retention (DAIR) in the Management of Prosthetic Joint Infections Following Primary Hip and Knee Arthroplaty: A DGH Experience

Abstract Aim Prosthetic joint infections (PJI) are a devastating complication of arthroplasty surgery. Current gold standard one or two-stage revision, poses sincere surgical challenges and carry significant patient morbidity. If diagnosed promptly, a debridement, antibiotics, and implant retention (DAIR) procedure can be performed. We report the results of our experience with the DAIR procedure in a District General Hospital setting. Method Our study comprises of a single centre retrospective review of a prospectively updated database. All patients who underwent a DAIR procedure following hip or knee arthroplasty from August 2012 to July 2019 were included in the study with no exclusions. Results Four total knee replacements, sixteen total hip replacements (THR), two revision THR and three hemiarthroplasties were included in the study. Average duration from onset of symptoms to DAIR was 22 days for immediate post-operative patients and 6 days in patients presenting later with an acute infection. All patients had exchange of modular components during the DAIR procedure. Out of 25 DAIR procedures, 23 identified a positive microbiology culture. Most common causative organisms identified were Staphylococcos aureus (23%) and Staphylococcus epidermidis (23%). Average follow up in clinic was 55 months. 76% of patients had a stable post-operative recovery with no recurrence of infection. One patient required a revision THR for aseptic loosening; one patient required a knee arthrodesis and four patients died. Conclusions Infection was successfully eradicated in 19 patients. The success reported within the literature stem predominantly from tertiary units. Our study reflects this success in a DGH setting.

Debridement, antibiotics and implant retention for prosthetic joint infection: comparison of outcomes between total hip arthroplasty and hip resurfacing.

The management of prosthetic joint infection (PJI) has been widely studied in the context of total hip arthroplasty (THA). However, the outcomes of debridement, antibiotics and implant retention (DAIR) for PJI have never been compared between hip resurfacing arthroplasty (HRA) and THA. This led us to carry out a retrospective case-control study comparing the surgical treatment of post-operative infections between HRA and THA to determine the infection remission rate and the medium-term functional outcomes. This single-centre case-control study analysed 3056 HRA cases of which 13 patients had a PJI treated by DAIR. These patients were age-matched with 15 infected THA hips treated by DAIR and modular component exchange (controls). Their survival (no recurrence of the infection) was compared and factors that could affect the success of the DAIR were explored: sex, body mass index, age at surgery, presence of haematoma, type of bacteria present and antibiotic therapy. At a mean follow-up of fiveyears (2-7), the infection control rate was significantly higher in the HRA group (100% [13/13]) than in the THA group (67% [10/15]) (p = 0.044). More patients in the THA group had undergone early DAIR (< 30days) (73% [11/15]) than in the HRA group (54% [7/13]). There was no significant difference between the two groups in the ASA score, presence of comorbidities, body mass index and duration of the initial arthroplasty procedure. At the review, the Oxford-12 score of 17/60 (12-28) was better in the HRA group than the score of 25/60 (12-40) in the THA group (p = 0.004). DAIR, no matter the time frame, is a viable therapeutic option for infection control after HRA.

A Multi-Disciplinary Approach for the Management of Prosthetic Joint Infections: An Australian Perspective.

Introduction:Prosthetic joint infections (PJI) are a major complication of hip and knee arthroplasty, imposing significant morbidity and mortality. Orthopaedic oncology units have utilised a multi-disciplinary team (MDT) approach for some time. PJI is not only an equally life-threatening condition, it also requires input from multiple healthcare personnel and treatment can vary significantly between individuals given the diversity in microbiological, surgical and host factors. Our arthroplasty service established an MDT meeting to manage this complex patient group. This study describes the philosophy and implementation of an MDT approach to the management of PJIs at a tertiary hospital in Australia.Materials and methods:A retrospective review of all patients that presented to the MDT PJI meeting from October 2017 to April 2020 was performed. Patient characteristics, microbiological profile and management were reviewed.Results:One hundred and one patients were reviewed over 2.5 years with a mean age of 69.2 years (SD 11.9). Patients presenting predominantly had a primary TKR (32%) or primary THR (22%). Results of Microbiology cultures varied, with 42% Gram-positive organisms, 13% Gram-negative organisms, 2% fungus and 1% yeast origin. Management mainly consisted of two-stage revision (28%), debridement-antibiotics-and-implant retention (22%) and antibiotic suppression (14%). A total of 91.5% of patients who underwent surgical management were considered cured at one year.Conclusion:PJIs are complex and require coordinated care by a number of healthcare personnel. The MDT process has allowed collaboration between Orthopaedic, Infectious Disease and Microbiology departments and aims to improve the quality of care provided to patients, potentially reducing morbidity and mortality of patients with PJI.