Periprosthetic Joint Infection Research Articles

The Investigation and Management of Peri-Prosthetic Joint Infection After Total Knee Arthroplasty: An Update Based on the Latest British Orthopaedic Association Standard and Speciality Standard Guidelines

The Investigation and Management of Peri-Prosthetic Joint Infection After Total Knee Arthroplasty: An Update Based on the Latest British Orthopaedic Association Standard and Speciality Standard Guidelines

Combined Use of External Iliac Lymph Node Count and Bone Scintigraphy for PJI Diagnosis: A Prospective Study

Background: The reactive enlargement of external iliac lymph nodes and increased blood flow in the infected region are commonly observed in lower limb infections. We aimed to differentiate between aseptic loosening and periprosthetic joint infection (PJI) after joint replacement surgery by quantifying the number of enlarged external iliac lymph nodes and using bone scintigraphy to monitor blood flow. Methods: We recruited 124 patients undergoing revision surgery for aseptic loosening or PJI. All the patients underwent preoperative dual-energy computed tomography (DECT) imaging for external iliac lymph nodes and bone scintigraphy. The diagnostic value was evaluated using ROC curve analysis. Results: The number of enlarged external iliac lymph nodes was significantly higher in the PJI group than in the aseptic failure group (4.0 versus. 1.0, p value < 0.001). The median affected/unaffected side ratio in the blood pool phase of ECT in the PJI group was 1.49, significantly higher than the aseptic failure group’s median ratio of 1.04 (p value < 0.001). The AUC for diagnosing PJI using the number of enlarged lymph nodes alone was 0.91, and when using the bone scintigraphy blood pool phase alone, the AUC was 0.89. When both metrics were combined, the AUC increased to 0.95, which was higher than the AUCs for the ESR (AUC = 0.83), CRP (AUC = 0.76), and synovial fluid PMN% (AUC = 0.62). Conclusions: Combining the enlargement of the lymph node count with the bone scintigraphy blood pool phase is a promising approach for diagnosing PJI.

Nanoparticle ultrasonication: a promising approach for reducing bacterial biofilm in total joint infection-an in vivo rat model investigation.

While the benefits of sonication for improving periprosthetic joint infection (PJI) are well-documented, its potential therapeutic effect against bacterial biofilm remains unstudied. This study aimed to investigate the safety and efficacy of a novel nanoparticle ultrasonication process on methicillin-resistant Staphylococcus aureus (MRSA) bacterial biofilm formation in a PJI rat model. This novel ultrasonication process was designed to remove attached bacterial biofilm from implant and peri-articular tissues, without damaging native tissues or compromising implant integrity. Twenty-five adult Sprague-Dawley rats underwent a surgical procedure and were colonized with intra-articular MRSA, followed by the insertion of a titanium screw. Three weeks after the index surgery, the animals received a second procedure during which the screws were explanted, and soft tissue was sampled. The intraoperative use of the nanoparticle sonication treatment was employed to assess the device's safety, while ex vivo treatment on the retrieved tissue and implants was used to evaluate its efficacy. Clinical and histological assessments did not indicate any macro- or micro-damage to the host tissue. Sonication of the retrieved tissues demonstrated an average bacterial removal of 2 × 103CFU/mL and 1 × 104CFU/gram of tissue. Compared to the standard-of-care group (n = 10), implants treated with sonication (n = 15) had significantly lower remaining bacteria, as indicated by crystal violet absorbance measurements (P = 0.012). This study suggests that nanoparticle sonication technology can successfully remove attached bacterial biofilms from explanted orthopedic hardware and the joint capsule, without negatively affecting native tissue. The study provides initial results supporting the potential of nanoparticle sonication as an adjuvant treatment option during a DAIR (debridement, antibiotics, and implant retention) procedure for PJI, paving the way for future clinical trials.

Multicenter Randomized Clinical Trial of Highly Cross-Linked Polyethylene Versus Conventional Polyethylene in 518 Primary TKAs at 10 Years

Background: Second-generation highly cross-linked polyethylene (HXLPE) has revolutionized total hip arthroplasty. However, the long-term risks and benefits of HXLPE in primary total knee arthroplasty (TKA) remain unknown. This randomized clinical trial evaluated implant survivorship, complications, radiographic results, and clinical outcomes of HXLPE and conventional ultra-high molecular weight polyethylene (UHMWPE) inserts in primary TKAs. Methods: We enrolled 518 patients (518 knees) who underwent primary TKA in 3 centers within 1 tertiary referral network. The mean age was 67 years, the mean body mass index was 32 kg/m2, and 58% of the patients were women. All of the patients underwent primary TKA with a cemented posterior-stabilized tibial insert and patellar resurfacing. Randomization proceeded via stratified dynamic allocation. The patients were blinded to their study group allocation: those in the control group (254 knees) underwent TKA with an UHMWPE insert (N2Vac; Stryker); those in the treatment group (264 knees) received an HXLPE insert (X3; Stryker). Kaplan-Meier survivorship, radiographic results, and clinical outcomes were assessed. This trial was registered with ClinicalTrials.gov. The mean follow-up was 11 years. Results: The 10-year overall survivorship free from any revision and from any reoperation was 96% and 94%, respectively. There were no differences in the risk of revision or reoperation between the groups (p > 0.05). There were a total of 19 revisions. Revision indications included periprosthetic joint infection (14 knees), instability (4 knees), and open reduction and internal fixation (ORIF) for a patellar fracture due to osteolysis around a UHMWPE insert (1 knee). There were no revisions due to polyethylene wear, osteolysis, or fracture of the post in the HXLPE group. The radiographic results and clinical outcomes were otherwise similar. Conclusions: Notably, no wear-related failures were identified in the HXLPE group, but there was 1 case of osteolysis in the UHMWPE group. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Does Body Mass Index Affect the Success of Two-Stage Management of Periprosthetic Joint Infection?

IntroductionObesity is associated with increased infection risk after primary total joint arthroplasty. In this retrospective cohort analysis, we sought to assess the association between body mass index (BMI) and infection recurrence after two-stage revision total joint arthroplasty (TJA) for periprosthetic joint infection (PJI). MethodsPatients were grouped by BMI (< 30, 30 to 40, and ≥ 40) as non-obese, obese, and morbidly obese, and assessed for associations and timing of PJI reinfection as well as readmissions and complications. ResultsFollowing the two-stage revision, PJI reinfections increased from 11.5% in non-obese to 19.0% in obese and 25.9% in morbidly obese patients (P = 0.011). As BMI increased across the three groups, 90-day readmission rates following two-stage PJI revision significantly increased (8.6, 19.7, and 16.7%, respectively (P = 0.042)). The average time to reinfection decreased with obesity tercile (restricted-mean times of 4.5, 4.2, and 3.8 years with non-obese, obese, and morbidly obese, respectively (P = 0.023)). DiscussionThe success of PJI management with two-stage arthroplasty is significantly impacted by patient BMI, with morbidly obese subjects having the worst outcomes. Attempts to modify BMI before completion of two-stage PJI treatment should be considered in the morbidly obese given high rates of recurrence.

Analysis of Serum and Synovial Inflammatory Markers in Periprosthetic Joint Infections: A Narrative Review.

Periprosthetic joint infection (PJI) is considered a rare but devastating complication after total joint arthroplasty (TJA). The problem lies in the fact that there is a paucity of "gold standard" diagnostic tests that make the diagnosis of PJI extremely challenging. Recently, there have been increasing evidence-based guidelines that have been introduced to standardise the approach to a patient with a suspected PJI. Diagnosing a case of PJI traditionally involves initial screening for elevated serum inflammation markers C-reactive protein (CRP) (mg/dL) and erythrocyte sedimentation rate (ESR), and aspiration remains the sole confirmatory investigation. However, several factors would affect the values of the aforementioned markers, such as gender, age, and the presence of inflammatory circumstances. Serum D-dimer that detects fibrinolytic activities during infection has high sensitivity, but the specificity was not persuasive as it would elevate during other conditions, such as venous thromboembolism. Therefore, there is also a need for a simultaneous and secondary marker. There are also several synovial biomarkers, including ESR, CRP, alpha-defensin, and synovial fluid leukocyte count and differential for the detection of PJI. In this narrative review, we want to sum up the serum and inflammatory markers that have been introduced so far for detecting PJI.

Data-Driven Approach to Development of a Risk Score for Periprosthetic Joint Infections in Total Joint Arthroplasty Using Electronic Health Records

Periprosthetic joint infection (PJI) is an uncommon, but serious complication in total joint arthroplasty. Personalized risk prediction and risk factor management may allow better preoperative assessment and improved outcomes. We evaluated different data-driven approaches to develop surgery-specific PJI prediction models using large-scale data from the electronic health records. A large institutional arthroplasty registry was leveraged to collect data from 58,574 procedures of 41,844 patients who underwent at least one primary and/or revision hip and/or knee arthroplasty between 2000 and 2019. The registry dataset was augmented with additional clinical, procedural, and laboratory data from the electronic health records for more than 100 potential predictor variables. The main outcome was PJI within the first year after surgery. We implemented both traditional and machine learning methods for model development (lasso regression, relaxed lasso regression, ridge regression, random forest, stepwise regression, extreme gradient boosting, neural network) and used 10-fold cross-validation to calculate measures of model performance in terms of discrimination (c-statistic), cross-entropy loss, and calibration. All models performed similarly in predicting PJI risk, with negligible differences of less than 0.08 between the best and worst-performing models. The relaxed and fully relaxed lasso models using the Cox model structure outperformed the other models with concordances of 0.787 in primary hip arthroplasty and 0.722 in revision hip arthroplasty, with the number of predictors ranging from nine to 41. The concordances with the relaxed lasso models were 0.681 in primary and 0.699 in revision knee arthroplasty, with a higher number of predictors in the models. Predictors included in the models varied substantially across the four surgical groups. The incorporation of additional data from the electronic health records offers limited improvement in PJI risk stratification. Furthermore, improvement in PJI risk prediction was modest with the machine learning approaches and may not justify the added complexity.

The occurrence of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) after arthroplasty mimicking a periprosthetic joint infection: A case report and literature review.

As the elderly population grows, the number of joint arthroplasty surgeries is also increasing. Periprosthetic joint infection (PJI) is a postoperative complication that occurs in 1%-2% of the arthroplasties. Once it occurs, PJI is refractory to treatment. Similar symptoms of PJI, including joint synovitis and elevated body temperature, sometimes arise because of crystal arthritis, rheumatoid arthritis, or other inflammatory diseases. Precise diagnosis is essential for determining the optimal treatment strategy. An 81-year-old female patient with a history of bilateral knee arthroplasty presented with a high fever of 38 °C and was unable to walk due to swelling and pain in the bilateral lower extremities. Infectious conditions, such as cellulitis or PJI, were suspected. Imaging findings revealed bilateral knee joint synovitis with pitting edema around the lower extremities, and cultures of bilateral joint fluids were negative. No crystals were observed in the joint fluid. Laboratory data revealed highly elevated levels of inflammatory marker; however, antinuclear antibodies, including rheumatoid factor and cyclic citrullinated peptide, were not detected. Based on bilateral synovitis with pitting edema in the lower extremities, in addition to negative culture findings and normal antinuclear antibodies, the diagnosis of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) was made. Steroid therapy was performed. The dose was gradually reduced, with the improvement of the symptoms. The inflammatory reaction promptly decreased and then normalized. With improved inflammation, the symptoms of pitting edema, pain in the bilateral lower extremities, and fluid effusion of the knee joints were reduced. She was able to walk without a cane, and her activities of daily living fully recovered. High fever and synovitis after joint arthroplasty do not necessarily indicate an infectious condition. Clinicians should be familiar with the occurrence of RS3PE, regardless of whether arthroplasty is performed.

Benefits and Adverse Events Associated With Extended Antibiotic Use for One Year Following Periprosthetic Joint Infection in Total Knee Arthroplasty: A Prospective Cohort Analysis.

Periprosthetic joint infections (PJIs) are common and serious complications following knee and hip arthroplasty. Our previous retrospective study suggested extended antibiotics following debridement, antibiotics, and implant retention (DAIR) decreased failure rates and were not associated with increased adverse events (AEs) as compared to a standard 6 weeks of antibiotic therapy. Further, extended antibiotics beyond one year did not provide additional benefits. These observations were tested in this prospective cohort study. A prospective cohort of patients who underwent DAIR for total knee arthroplasty PJI and received primary antibiotics were compared to patients who received primary antibiotics combined with extended antibiotics for one year. Participants had a minimum of 2-year follow-up after the final dose of antibiotics. A prospective cohort of 79 patients was followed, where 39 participants (52.7%) received primary antibiotics and 35 participants (47.3%) received both primary and extended antibiotics following DAIR. Multivariable time-to-event analyses revealed that extended antibiotic use was an independent predictor of treatment success. Infection-free survival differed significantly between the two treatment regimens, as the hazard of PJI failure was significantly lower for extended antibiotics as compared to primary antibiotics alone (adjusted hazard ratio [HR]= 0.46 [0.24 to 0.87], P= 0.017). The AE rates did not significantly differ between patients treated with primary antibiotics only versus primary combined with extended antibiotics. This prospective cohort study supports our previous observations that extended antibiotics for one year were associated with lower failure rates as compared to primary antibiotics alone. Extended antibiotics after primary antibiotics were not found to be associated with increased AEs as compared to only primary antibiotics.

Early adverse outcomes remain challenging to prevent in morbidly obese patients undergoing total hip arthroplasty.

The prevalence of obesity is increasing substantially around the world. Elevated BMI increases the risk of complications following total hip arthroplasty (THA). We sought to evaluate trends in BMI and complication rates of obese patients undergoing primary THA over the last 30 years. Through our institutional total joint registry, we identified 15,455 primary THAs performed for osteoarthritis from 1990 to 2019. Patients were categorized according to the World Health Organization (WHO) obesity classification and groups were trended over time. Cox proportional hazards regression analysis controlling for confounders was used to investigate the association between year of surgery and two-year risk of any reoperation, any revision, dislocation, periprosthetic joint infection (PJI), venous thromboembolism (VTE), and periprosthetic fracture. Regression was stratified by three separate groups: non-obese; WHO Class I and Class II (BMI 30 to 39 kg/m2); and WHO Class III patients (BMI ≥ 40 kg/m2). There was a significant increase in the proportion of all obesity classes from 1990 to 2019, and the BMI values within each WHO class significantly increased over time. Risk of any reoperation did not change over time among non-obese or WHO Class I/II patients, but increased for WHO Class III patients (hazard ratio (HR) 1.04; p = 0.044). Risk of dislocation decreased over time for non-obese (HR 0.96; p < 0.001) and WHO Class I/II (HR 0.96; p = 0.002) patients, but did not change over time for WHO Class III (HR 0.94; p = 0.073) patients. Risks of any revision and PJI did not change over time for any group. The proportion of patients undergoing THA who are obese has increased dramatically at our institution between 1990 and 2019. Despite BMI values increasing within all WHO classes over time, two-year complication risks have remained stable or decreased in WHO Class I/II patients. However, continued efforts will be required to mitigate risks in the heaviest WHO Class III patients.

Moving Beyond Systemic Inflammatory Response Syndrome and Bacteremia: Are Modern Critical Care Calculators Useful in Predicting Debridement, Antibiotics, and Implant Retention Treatment Outcomes in Periprosthetic Joint Infection?

BackgroundIn critically ill periprosthetic joint infection (PJI) patients, surgeons need to balance the need for aggressive, definitive treatment against the health state of a potentially unstable patient. A clear understanding of the association between treatment outcomes and assessment scores for sepsis would benefit clinical decision-making in these urgent cases. The current study evaluates the effect of critical illness on debridement, antibiotics, and implant retention (DAIR) outcomes, as defined by systemic inflammatory response syndrome (SIRS) and, for the first time, by contemporary markers quick Sequential Organ Failure Assessment (qSOFA) and Modified Early Warning Score (MEWS). MethodsWe retrospectively identified 253 patients who underwent DAIR for PJI at a single institution between 2017 and 2021. The SIRS, qSOFA, and MEWS scores were calculated based on variables on admission. A DAIR treatment failure, defined as reoperation or mortality, was measured at 90 days and two years. Univariate analysis was used to determine the association between elevated critical care scores and DAIR failure. ResultsThe DAIR treatment success was 59% at two years, with hip procedures and Charlson comorbidity index (CCI) ≥ 1 independently associated with higher odds of DAIR failure. There were 43 patients (16%) who presented with SIRS, however, only four (2%) had positive qSOFA scores. Neither SIRS nor qSOFA were predictive of DAIR failure. For knees only, elevated MEWS scores were predictive of 90-day DAIR failure (P = 0.019). ConclusionOver one in six patients undergoing DAIR for PJI presented with SIRS, while only one in 50 had a positive qSOFA. The SIRS and qSOFA scores were not predictive of DAIR failure. Elevated MEWS scores were associated with DAIR failure at 90 days postoperatively in knee PJIs only, and should be confirmed in a larger cohort. Our results suggest that SIRS is not predictive of DAIR outcomes, possibly because it overestimates the proportion of critically ill patients.

Clinical and Radiographic Outcomes of a Long Cementless Monobloc Stem for Revision Total Hip Arthroplasty Due to Chronic Periprosthetic Infection

BackgroundA long cementless monobloc stem is widely used for aseptic loosening, with satisfactory five-to-ten-year outcomes reported. Nonetheless, related studies on chronic periprosthetic joint infection (PJI) are scant. This study evaluated the clinical and radiographic outcomes of the stem in two-stage revisions due to PJI. MethodsThis prospective multicenter cohort study consisted of patients from three medical centers who were enrolled in a single arm from January 2017 to May 2022. All patients were diagnosed with chronic PJI based on International Consensus Meeting (ICM) criteria and underwent two-stage revisions using a long monobloc cementless revision stem. Among 44 patients, 37 (12 women and 25 men) completed an average follow-up of 35.6 months (range, 14 to 75). The primary outcome was the stability of the stem; secondary outcomes included infection eradication, Harris hip score, leg length discrepancy, major complications, and isolated pathogens at intraoperative cultures. ResultsAt one year after revision, the infection-free prosthesis survival rate was 97.3% (95% CI [confidence interval]: 96.4 to 98.2%). At the last follow-up, the mean subsidence was 2.9 ± 2.1 mm (range, 0.8 to 4.8). Postoperative leg length discrepancy averaged −4.6 ± 4.9 mm (range, −16 to 0). The Engh score averaged 14.1 ± 6.9 (range, 0 to 22). The Harris hip score improved from a preoperative average of 35.7 ± 8.5 (range, 12 to 50) to 80.4 ± 9.3 (range, 58 to 92) at the 1-year postoperative follow-up (P < 0.01). ConclusionThe long cementless monobloc stem used in the current study presents a feasible option for two-stage revision in cases of chronic PJI. The bone ingrowth and stability could be observed within the short follow-up time.

Miconazole-splitomicin combined β-glucan hydrogel for effective prevention of Candida albicans Periprosthetic Joint Infection

As one of the most common and serious infections caused by Candida albicans (C. albicans), periprosthetic joint infection (PJI) increasingly concerns surgeons and scientists. Generally, biofilms shield C. albicans from antifungal agents and immune clearance and induce drug-resistant strains. Developing novel strategies for PJI to get rid of current drug-resistant problems is highly needed. In our study, splitomicin (SP) can inhibit the mycelium formation of C. albicans and enhance the drug sensitivity of C. albicans to miconazole nitrate (MCZ). The combination of SP and MCZ significantly inhibited the viability, proliferation and adhesion of C. albicans, reduced the yeast to hyphae transition and biofilm formation. When SP and MCZ were coloaded in the β-glucan hydrogel, a viscoelastic solid with porous 3D network, sustained release and erosion properties was obtained. In the in vivo PJI mice model, SP-MCZ-β-glucan hydrogel effectively reduced the colonization and aggregation of C. albicans around the implant, reduced the pathological changes caused by C. albicans in the femur tissue. Therefore, SP-MCZ-β-glucan hydrogel holds a great promise for the management of C. albicans infection around joint prosthesis.

Low-Volume Surgeons Operating at High-Volume Hospitals Have Low Rates of Periprosthetic Joint Infection after Hip and Knee Arthroplasty

IntroductionThe relationship between surgeon and hospital case volumes and postoperative risk following total hip and total knee arthroplasty (THA and TKA) has been described independently. This study aimed to assess the risk of periprosthetic joint infection (PJI) following primary TKA and THA to determine if lower volume surgeons operating at higher volume centers would have lower rates of complications compared to lower volume surgeons operating at lower volume hospitals. MethodsA healthcare database was used to retrospectively identify all primary, and elective total joint arthroplasties (TJAs) from October 2015 to December 2021. Using restricted cubic splines, high-volume hospitals were defined using Markov chain Monte Carlo simulation, which identified a volume beyond which PJI rates no longer decreased significantly with increasing hospital volume. A similar methodology was used to identify low-volume surgeons operating in high- and low-volume hospitals. There were 605,254 patients who underwent TJA (total hip arthroplasty [THA]: 37.71%; total knee arthroplasty [TKA]: 62.29%) by low-volume surgeons (< 57 THAs and < 68 TKAs) identified and divided into high-volume and low-volume hospital cohorts. High-volume hospitals were defined as > 508 THA and > 812 TKAs per year, and low-volume hospitals were defined as < 145 THAs and < 243 TKAs per year. Multivariable models accounting for potential confounding covariates were created to determine the odds of PJI between cohorts. ResultsAfter taking confounding variables into account, low-volume surgeons at high-volume hospitals had lower rates of PJI relative to their counterparts at low-volume hospitals (THA 0.67 versus 0.80%, aOR [adjusted odds ratio] = 0.69 [95% confidence interval (CI) = 0.54 to 0.88], P = 0.002; TKA 0.51 versus 0.69%, aOR = 0.73, [95%-CI = 0.61 to 0.87], P = 0.007). ConclusionIncreasing institutional case volume may mitigate the increased risk of PJI associated with low annual surgeon case volume.

Anti-Osteoporotic Treatment Reduces Risk of Revision Following Total Shoulder Arthroplasty in Patients with Osteoporosis

Osteoporosis, a prevalent bone density disorder, introduces a complex dynamic in the context of total shoulder arthroplasty (TSA). However, despite the well-established association between osteoporosis and an elevated risk of revision, the existing literature lacks comprehensive insights into the impact of anti-osteoporotic therapy on surgical outcomes in the setting of TSA. Thus, the purpose of this study was to investigate whether anti-osteoporotic therapy correlates with improved revision outcomes following TSA. A retrospective cohort analysis was performed using a national all payer's claims database. Patients who underwent TSA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) procedure codes. Patients with a preoperative diagnosis of osteoporosis were included, then stratified into two groups: (1) patients with osteoporosis who underwent anti-osteoporotic therapy within 6 months prior to surgery (Anti-OP cohort) and (2) patients with osteoporosis who never received anti-osteoporotic treatment (No Anti-OP cohort). Primary outcomes included the incidence of 2-year all-cause revision, periprosthetic fracture (PPF), periprosthetic joint infection (PJI), and mechanical loosening. Univariate and multivariable regression analysis was conducted to compare outcomes between the two cohorts. In total, 40,532 osteoporotic patients were included in this study, with 11,577 (28.5%) having undergone anti-osteoporotic treatment. Patients who did not receive anti-osteoporotic treatment had significantly higher odds of 2-year all-cause revision (Odds Ratio [OR]: 1.31; P < 0.001) and mechanical loosening (OR: 1.25; P < 0.001) following TSA when compared to those treated for osteoporosis. This study demonstrates a significant association between anti-osteoporotic therapy and reduced rates of 2-year revision following TSA. Orthopedic surgeons should recognize the heightened risk of early implant failure in the absence of osteoporosis therapy. This underscores the imperative for increased screening initiatives given the high prevalence of undiagnosed or untreated osteoporosis in the TSA population. These results also emphasize the importance of integrating osteoporosis management strategies into the broader context of surgical decision-making, thereby contributing to enhanced patient outcomes and quality of care in shoulder surgery.

A dual-aptamer sandwich assay by detection of c-reactive protein in synovial fluid on an integrated microfluidic system for diagnosis of periprosthetic joint infection

Diagnosing periprosthetic joint infection (PJI) in equivocal cases is always challenging. Synovial fluid (SF) C-reactive protein (CRP) levels have been reported as a surrogate to improve the diagnosis accuracy. This study reported a new integrated microfluidic system (IMS) designed to detect SF-CRP at a dynamic range of 1-50mg/L. The novel, magnetic bead-based, dual-aptamer assay with two CRP-specific aptamers, St1 and St2, enabled rapid and accurate CRP detection. This represents the first attempt to automatically perform the CRP dual-aptamer assay on a microfluidic chip quantifying CRP in SF with optical signals. CRP concentrations in fourteen clinical samples were accurately quantified by using the dual-aptamer assay on the developed IMS in an automatic format, suggesting the assay’s potential as a reliable diagnostic tool for SF-CRP detection and may serve as an armamentarium for PJI diagnosis. Notably, the assay was deemed superior to traditional enzyme-linked immunosorbent assay (ELISA) because it consumes a smaller amount of sample (only 40μL), requires fewer reagents (only 50μL of secondary detection aptamer and horseradish peroxidase), and provides quicker results (~2hours).

Treatment Failure Rates Significantly Decrease at One and Five Years After Debridement, Antibiotics, and Implant Retention for Acute Periprosthetic Joint Infection in Total Knee Arthroplasty: A 10 Year Cohort Study

Treatment Failure Rates Significantly Decrease at One and Five Years After Debridement, Antibiotics, and Implant Retention for Acute Periprosthetic Joint Infection in Total Knee Arthroplasty: A 10 Year Cohort Study

Periprosthetic Joint Infection in Patients With Inflammatory Arthritis: Optimal Tests to Differentiate From Flares.

Diagnosis of periprosthetic joint infection (PJI) in patients with inflammatory arthritis (IA) is challenging, as features of IA flares can mimic infection. We aimed to cross-sectionally determine if the optimal tests to diagnose PJI in osteoarthritis were present in patients with IA flares. We enrolled patients from October 2020 to July 2022 in 3 groups: (a) PJI-total joint arthroplasty patients undergoing revision for infection, (b) IA Flare-IA patients with a flaring native joint, and (c) IA Aseptic-total joint arthroplasty patients with IA undergoing aseptic arthroplasty revision. We compared blood and synovial fluid markers between the cohorts using Kruskal-Wallis and Fisher exact tests to assess marker sensitivity and specificity. Of 52 cases overall, 40% had rheumatoid arthritis, 20% psoriatic arthritis, and 11% osteoarthritis (in PJI group). PJI cases had higher C-reactive protein (CRP) and synovial fluid polymorphonuclear neutrophil percentage (%PMN). Alpha-defensin tested positive in 93% of PJI cases, 20% of IA Flares, and 6% of IA Aseptic (p < 0.01). Synovial white blood cell count >3000/μL and positive alpha-defensin were highly sensitive (100%) in diagnosing infection; however, specificity was 50% for white blood cell counts and 79% for alpha-defensin. PJI diagnosis was nearly 5 times more likely with positive alpha-defensin and almost 6 times more likely with %PMNs >80. Blood markers interleukin-6, procalcitonin, and d-dimer were neither sensitive nor specific, whereas erythrocyte sedimentation rate and CRP showed 80% sensitivity, but 47% and 58% respective specificities. Although synovial %PMNs, CRP, and alpha-defensin are sensitive tests for diagnosing PJI, they are less specific and may be positive in IA flares.

Shoulder Periprosthetic Joint Infection: Principles of Prevention, Diagnosis, and Treatment.

➢ Shoulder periprosthetic joint infection (PJI) is a potentially devastating complication after arthroplasty and is projected to rise with increasing numbers of performed arthroplasties, particularly reverse shoulder arthroplasties.➢ Important considerations for the diagnosis and treatment of shoulder PJI include age, sex, implant type, primary compared with revision shoulder surgery, comorbidities, and medications (i.e., corticosteroids and disease-modifying antirheumatic drugs).➢ Diagnosis and management are unique compared with lower-extremity PJI due to the role of lower-virulence organisms in shoulder PJI, specifically Cutibacterium acnes.➢ Treatment pathways depend on chronicity of infection, culture data, and implant type, and exist on a spectrum from irrigation and debridement to multistage revision with temporary antibiotic spacer placement followed by definitive revision arthroplasty.

The DAIR-procedure in fracture-related infection–When and how

This narrative review discusses treatment strategies and key considerations guiding decisions in the surgical management of fracture-related infections (FRI). Treatment options primarily revolve around two approaches: debridement antibiotics and implant retention (DAIR), or implant exchange, either in a one or multiple-stage strategy. Several considerations, including time since infection onset, implant type, stability, causative pathogens, host physiology, and soft tissue conditions, inform the choice of surgical intervention for FRI. Current literature supports the preference for a DAIR approach in cases with a short duration of ongoing symptoms, a stable implant with satisfactory fracture reduction, and a viable soft tissue envelope. Conversely, one- or multiple-stage implant exchange is deemed beneficial in instances of compromised local and systemic host physiology, mature biofilm, difficult-to-treat pathogens, intramedullary implants, and cases involving reinfections or failed DAIR procedures. Notably, these recommendations draw parallels from periprosthetic joint infection treatment strategies, constrained by the limited availability of randomized controlled trials comparing these options specifically in acute FRI. In conclusion, future perspectives call for extensive investigations into biofilm maturation and the impact of time on treatment outcomes. Additionally, there is a need for a standardized classification system for FRI to enhance the comparability of treatment outcomes in FRI management.