Prevention Of Periprosthetic Joint Infection Research Articles

Comparison of the effect of combined usage of povidone-iodine irrigation and topical vancomycin powder to the use of povidone-iodine irrigation alone on the periprosthetic joint infection incidence rate in patients undergoing primary total hip and knee arthroplasty: a protocol for multicenter prospective randomized clinical trial

BackgroundWith the increasing number of joint replacement surgeries, periprosthetic joint infection (PJI) has become a significant concern in orthopedic practice, making research on PJI prevention paramount. Therefore, the study will aim to compare the effect of combined usage of povidone-iodine and topical vancomycin powder to the use of povidone-iodine alone on the PJI incidence rate in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA).MethodsThe prospective randomized clinical trial will be conducted in two independent voivodeship hospitals with extensive experience in lower limb arthroplasties. The studied material will comprise 840 patients referred to hospitals for primary THA or TKA. The patients will be randomly allocated to two equal groups, receiving two different interventions during joint replacement. In group I, povidone-iodine irrigation and consecutively topical vancomycin powder will be used before wound closure. In group II, only povidone-iodine lavage irrigation will be used before wound closure. The primary outcome will be the incidence rate of PJI based on the number of patients with PJI occurrence within 90 days after arthroplasty. The occurrence will be determined using a combined approach, including reviewing hospital records for readmissions and follow-up phone interviews with patients. The infection will be diagnosed based on Musculoskeletal Infection Society criteria. The chi-square test will be used to compare the infection rates between the two studied groups. Risk and odds ratios for the between-groups comparison purposes will also be estimated. Medical cost analysis will also be performed.DiscussionA randomized clinical trial comparing the effect of combined usage of povidone-iodine irrigation and vancomycin powder to the use of povidone-iodine irrigation alone in preventing PJIs after primary arthroplasty is crucial to advancing knowledge in orthopedic surgery, improving patient outcomes, and guiding evidence-based clinical practices.Trial registrationClinicalTrials.gov NCT05972603. Registered on 2 August 2023.

Comparison of the effect of combined usage of povidone-iodine irrigation and topical vancomycin powder to the use of povidone-iodine irrigation alone on the periprosthetic joint infection incidence rate in patients undergoing primary total hip and knee arthroplasty: a protocol for multicenter prospective randomized clinical trial

BackgroundWith the increasing number of joint replacement surgeries, periprosthetic joint infection (PJI) has become a significant concern in orthopedic practice, making research on PJI prevention paramount. Therefore, the study will aim to compare the effect of combined usage of povidone-iodine and topical vancomycin powder to the use of povidone-iodine alone on the PJI incidence rate in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA).MethodsThe prospective randomized clinical trial will be conducted in two independent voivodeship hospitals with extensive experience in lower limb arthroplasties. The studied material will comprise 840 patients referred to hospitals for primary THA or TKA. The patients will be randomly allocated to two equal groups, receiving two different interventions during joint replacement. In group I, povidone-iodine irrigation and consecutively topical vancomycin powder will be used before wound closure. In group II, only povidone-iodine lavage irrigation will be used before wound closure. The primary outcome will be the incidence rate of PJI based on the number of patients with PJI occurrence within 90 days after arthroplasty. The occurrence will be determined using a combined approach, including reviewing hospital records for readmissions and follow-up phone interviews with patients. The infection will be diagnosed based on Musculoskeletal Infection Society criteria. The chi-square test will be used to compare the infection rates between the two studied groups. Risk and odds ratios for the between-groups comparison purposes will also be estimated. Medical cost analysis will also be performed.DiscussionA randomized clinical trial comparing the effect of combined usage of povidone-iodine irrigation and vancomycin powder to the use of povidone-iodine irrigation alone in preventing PJIs after primary arthroplasty is crucial to advancing knowledge in orthopedic surgery, improving patient outcomes, and guiding evidence-based clinical practices.Trial registrationClinicalTrials.gov NCT05972603. Registered on 2 August 2023.

Implementation of Outpatient Parenteral Antimicrobial Therapy (OPAT) in Patients with Complicated Periprosthetic Joint Infections.

Periprosthetic joint infections (PJI) are a serious complication of arthroplasty with high morbidity. With growing bacterial resistance and limited disposability of oral antibiotics with sufficient bioavailability, the need for intravenous antibiotic application is raising. This causes long-term hospital stays and rising costs. In the course of transferring procedures into an outpatient setting as well as coping with pressures on hospital capacity, outpatient parenteral antimicrobial therapy (OPAT) can build a bridge for the treatment of such infections.In a single centre analysis, 47 cases treated with OPAT were studied in relation to pathogen, antimicrobial resistance, indication for OPAT and follow up. Furthermore, the patients received an anonymised questionnaire with 4 clusters of interest in terms of internal quality assessment on the success and evaluation of this therapeutic procedure. Special attention was paid to the descriptive analysis of patients with periprosthetic joint infections (n=30).Between May 2021 and October 2022 out of 47 patients with OPAT, 30 cases with periprosthetic joint infections were identified. For infected hip- and knee arthroplasties, a remarkable spectrum of pathogens was found. In hip infections highly resistant strains of Staphylococcus epidermidis and Enterococci were detected. In knee infections, the pathogens were more susceptible, but however highly virulent Staphylococcus aureus and Streptococci. Difficult to treat, mixed infections were found in both locations. The indication for OPAT was based in half of the cases on the high level of antimicrobial resistance, with availability of only parenteral applicable antibiotics. Further indications were mixed infections and difficult to treat pathogens, with flucloxacillin therapy as well as OPAT as the last therapeutic option. The questionnaire showed 96% patient satisfaction in terms of organisation and acceptance of this kind of therapy. Complications or unexpected outpatient/ hospital treatments were very rare in connection with OPAT. Two thirds of patients reported completion of the treatment. In the clinical follow up (average of 5.7 months), 96.6% of cases were declared free of infection. In one patient the infection persisted.OPAT is a safe and reliable therapeutic option for outpatients to continue parenteral antimicrobial treatment in joint infections. Due to increasing pressure on hospitals in terms of costs and capacity, this therapy offers an alternative to inpatient treatment. The indication for OPAT should be set individually, risk adjusted and not generalised for all patients. The outpatient sector needs financial and structural support for comprehensive roll-out of this treatment in Germany. A further focus should be on the prevention of periprosthetic joint infections. With the knowledge of the expected pathogens and the surgical resources, the standards should be adapted. The choice of the antibiotic should be specified and the intervals of application be shortened, according to the surgical course, in order to yield high levels of agent concentration in the surgical area. Further investigations are required to test the superiority of OPAT versus the oral administration of antibiotics in long-term observations as well as to define the necessary duration of OPAT.

Efficacy of Intrawound Vancomycin in Prevention of Periprosthetic Joint Infection After Primary Total Knee Arthroplasty: A Prospective Double-Blinded Randomized Control Trial

BackgroundPeriprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a devastating complication. Intrawound vancomycin powder has been shown to reduce infection rates in spine surgery, but its role in arthroplasty remains controversial. This prospective randomized control trial aimed to evaluate the efficacy of intrawound vancomycin in preventing PJI after primary TKA. MethodsA total of 1,022 patients were randomized to the study group (n = 507, who received 2 grams intrawound vancomycin powder before arthrotomy closure) or to the control group (n = 515, no local vancomycin) with a minimum follow-up of 12-months. The primary outcome was the incidence of PJI or surgical site infection (SSI). Secondary outcomes included associated minor complications such as stitch abscess, persistent wound drainage, and delayed stitch removal. Other parameters evaluated include reoperation rates and incidences of nephrotoxicity. ResultsThe overall infection rate in 1,022 patients was 0.66%. There was no significant difference in PJI rate in the study group (N = 1; 0.2%) versus the control group (N = 3; 0.58%), P = .264. Reoperation rates in the study group (N = 4; 0.78%) and control (N = 5; 0.97%), and SSI rates in the study (N = 1; 0.2%) and control groups (N = 2; 0.38%) were comparable. The Vancomycin cohort, however, demonstrated a significantly higher number of minor wound complications (n = 67; 13.2%) compared to the control group (n = 39; 7.56%, P < .05). Subgroup analysis showed diabetics in the study group to also have a higher incidence of minor wound complications (24 [14.1%] versus 10 [6.2%]; P < 05]. Multivariate analyses found that vancomycin use (odds ratio = 1.64) and smoking (odds ratio = 1.85) were associated with an increased risk of developing minor wound complications. No cases of nephrotoxicity were reported. ConclusionsIntrawound vancomycin powder does not appear to reduce PJI/SSI rate in primary total knee arthroplasties, including high-risk groups. Although safe from a renal perspective, intrawound vancomycin was associated with an increase in postoperative aseptic wound complications. Intrawound vancomycin may not be effective in reducing the rate of PJI in primary TKA.

Infection Rates After Aseptic Revision Total Hip Arthroplasty With Extended Oral Antibiotic Prophylaxis.

Few US studies have investigated the efficacy of extended oral antibiotic prophylaxis (EOAP) in the prevention of periprosthetic joint infection (PJI) after aseptic revision total hip arthroplasty (R-THA). This study compared PJI rates in aseptic R-THA performed with EOAP with PJI rates in published studies of aseptic R-THA patients not receiving EOAP. Prospectively documented data on 127 consecutive aseptic R-THAs were retrospectively reviewed. Evidence-based perioperative infection prevention protocols were used, and all patients were discharged on 7-day EOAP. Superficial and deep infections at 30 and 90 days postoperatively and at mean latest follow-up of 27.8 months were statistically compared with all US studies reporting the prevalence of PJI after aseptic R-THA. Complications related to EOAP within 120 days of the index procedure also are reported. No superficial or deep infections were observed at 30 and 90 days postoperatively when 7-day postdischarge EOAP was used. Superficial and deep infection rates were 1.57% (two patients) and 3.15% (four patients) at mean latest follow-up, respectively. Comparisons with published 30-day PJI rates of 1.37% ( P = 0.423) and 1.85% ( P = 0.257) were not statistically significant. Two of four comparisons with published 90-day PJI rates of 3.43% ( P = 0.027) and 5.74% ( P = 0.001) were statistically different. The deep PJI rate of 3.15% at mean latest follow-up was significantly lower than two of three published rates at equivalent follow-up including 10.10% ( P = 0.009) and 9.12% ( P = 0.041). No antibiotic-related complications were observed within 120 days of the index procedure. Study findings possibly support the use of EOAP after aseptic R-THA to prevent catastrophic PJI with revision implants, indicating that the efficacy of EOAP cannot be definitively ruled-in or ruled-out based on available evidence.

A Periprosthetic Joint Candida albicans Infection Model in Mouse.

Periprosthetic joint infection (PJI) is one of the common infections caused by Candida albicans (C. albicans), which increasingly concerns surgeons and scientists. Generally, biofilms that can shield C. albicans from antibiotics and immune clearance are formed at the infection site. Surgery involving the removal of the infected implant, debridement, antimicrobial treatment, and reimplantation is the gold standard for the treatment of PJI. Thus, establishing animal PJI models is of great significance for the research and development of new drugs or therapeutics for PJI. In this study, a smooth nickel-titanium alloy wire, a widely used implant in orthopedic clinics, was inserted into the femoral joint of a C57BL/6 mouse before the C. albicans were inoculated into the articular cavity along the wire. After 14 days, mature and thick biofilms were observed on the surface of implants under a scanning electronic microscope (SEM). A significantly reduced bone trabecula was found in the H&E staining of the infected joint specimens. To sum up, a mouse PJI model with the advantages of easy operation, high successful rate, high repeatability, and high clinical correlation was established. This is expected to be an important model for clinical studies of C. albicans biofilm-related PJI prevention.

Diagnosis and Prevention of Periprosthetic Joint Infections by Staphylococcus aureus after Hip Fracture: A Systematic Review of the Literature.

Hip arthroplasties are surgical procedures widely performed all over the world, seeking to return functionality, relieve pain, and improve the quality of life of patients affected by osteoarthritis, femoral neck fractures, osteonecrosis of the femoral head, among other etiologies. Periprosthetic joint infections are one of the most feared complications due to the high associated morbidity and mortality, with a high number of pathogens that may be associated with its etiology. The aim of the present study was to analyze aspects correlated with the occurrence of infection, diagnosis and prevention of periprosthetic joint infections in the hip associated with Staphylococcus aureus after corrective surgery for hip fractures. This is a systematic review of the literature carried out in the databases indexed in the Medical Literature Analysis and Retrieval System Online (MEDLINE) carried out in accordance with the precepts established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Twenty studies that addressed the diagnosis and prevention of periprosthetic joint infections after hip fractures were selected for analysis. It is observed that there is no consensus in the literature on preventive measures for the occurrence of such infectious processes. Among the risk factors for the occurrence and severity of infections by S. aureus after hip arthroplasties, obesity, longer surgical time, older age, immunosuppression, recent use of antibiotics, and multicomorbidities were mentioned. The use of biomarkers for early diagnosis, as well as screening, decolonization, and antibiotic prophylaxis processes are among the preventive procedures proposed in the literature.

Estimating effectiveness of nasal decolonization in prevention of peri-prosthetic joint infection in nasal carriers of Staphylococcus aureus undergoing arthroplasty in a tertiary care institution

Introduction: Peri-prosthetic joint infection (PJI) is one of the most challenging complications after total joint arthroplasty (TJA) surgeries. This study aims to (i) compare overall PJI rates with and without pre-operative nasal screening and decolonization for Staphylococcus aureus; (ii) estimate the difference in SSI rates between carriers and non-carriers undergoing TJA; and (iii) determine the efficacy of decolonization in reducing PJI rate in nasal carriers. Methods: A total of 760 patients were included in the study; with 399 patients in the study group, who underwent pre-operative screening and decolonization for nasal colonization with S. aureus; and 361 patients in the control group, who did not undergo pre-operative screening for nasal colonization. Patients were followed for 90 days post-surgery, and PJI rates were recorded following the Centers for Disease Control SSI criteria. Results: Twenty-one (5.26%) out of 399 patients in the study group developed PJI as opposed to 38 (10.53%) out of 361 patients in the control group. PJI rate due to either MSSA or MRSA was 2.5% in the study group (10/399) as opposed to 7.75% in the control group (28/361), with “P value” of 0.002 (&lt;0.05). Discussion: The overall SSI incidence was reduced by 51% after implementing the decolonization protocol. Regarding specific S. aureus SSI, 7.5% of the SSIs in the control group were caused by S. aureus, while only 2.5% were caused by this microorganism after implementing the screening and decolonization protocol. Conclusion: Implementing a screening and decolonization protocol for S. aureus before TJA can lead to a significant reduction in S. aureus surgical site infections.

Comprehensive Guidance for the Prevention of Periprosthetic Joint Infection After Total Joint Arthroplasty and Pitfalls in the Prevention.

Total joint arthroplasty (TJA) is a surgical procedure, in which parts of damaged joints are removed and replaced with a prosthesis. The main indication of TJA is osteoarthritis, and the volume of TJA is rising annually along with the increase of aged population. Hip and knee are the most common joints, in which TJAs are performed. The TJA prosthesis is composed of metal, plastic, or ceramic device. Even though TJA is the most successful treatment for end-stage osteoarthritis, it is associated with various complications, and periprosthetic joint infection (PJI) is the most serious complication after TJA. With the increasing volume of TJAs, there is a simultaneous rise in the incidence of PJI. Contamination of the surgical wound and the adherence of bacteria to the surface of prosthetic component represent the initial step in the pathogenesis of PJI. The main sources of the contamination are 1) patient's own flora, 2) droplets in the operation room air, and 3) surgical gloves and instruments. Even though modern techniques have markedly reduced the degree of contamination, TJAs cannot be done in completely germ-free conditions and some degree of contamination is inevitable in all surgical procedures. However, not all contamination leads to PJI. It develops when the burden of contamination exceeds the immune threshold or the colony forming units (CFUs) and various factors contribute to a decrease in the CFU level. Surgeons should be aware of the germ burden/CFU concept and should monitor sources of contamination to maintain the germ burden below the CFU to prevent PJI.

Non-cefazolin antibiotic prophylaxis is associated with higher rates of elbow periprosthetic joint infection

Periprosthetic joint infection (PJI) is a common source of failure following elbow arthroplasty. Perioperative prophylactic antibiotics are considered standard of care. However, there are no data regarding the comparative efficacy of various antibiotics in the prevention of PJI for elbow arthroplasty. Previous studies in shoulder, hip, and knee arthroplasty have demonstrated higher rates of PJI with administration of non-cefazolin antibiotics. The elbow has higher rates of PJI than other joints. Therefore, this study evaluated whether perioperative antibiotic choice affects rates of PJI in elbow arthroplasty. A single-institution, prospectively collected total joint registry database was queried to identify patients who underwent primary elbow arthroplasty between 2003 and 2021. Elbows with known infection prior to arthroplasty (25) and procedures with incomplete perioperative antibiotic data (7) were excluded, for a final sample size of 603 total elbow arthroplasties and 19 distal humerus hemiarthroplasties. Cefazolin was administered in 561 elbows (90%) and non-cefazolin antibiotics including vancomycin (32 elbows, 5%), clindamycin (27 elbows, 4%), and piperacillin/tazobactam (2 elbows, 0.3%) were administered in the remaining 61 elbows (10%). Univariate and multivariate analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Infection-free survivorship was estimated using the Kaplan-Meier method. Deep infection occurred in 47 elbows (7.5%), and 16 elbows (2.5%) were diagnosed with superficial infections. Univariate analysis demonstrated that patients receiving non-cefazolin alternatives were at significantly higher risk for any infection (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.4-5.0; P<.01) and deep infection (HR 2.7, 95% CI 1.3-5.5; P<.01) compared with cefazolin administration. Multivariable analysis, controlling for several independent predictors of PJI (tobacco use, male sex, surgical indication other than osteoarthritis, and American Society of Anesthesiologists score), showed that non-cefazolin administration had a higher risk for any infection (HR 2.8, 95% CI 1.4-5.3; P<.01) and deep infection (HR 2.9, 95% CI 1.3-6.3; P<.01). Survivorship free of infection was significantly higher at all time points for the cefazolin cohort. In primary elbow arthroplasty, cefazolin administration was associated with significantly lower rates of PJI compared to non-cefazolin antibiotics, even in patients with a greater number of prior surgeries, which is known to increase the risk of PJI. For patients with penicillin or cephalosporin allergies, preoperative allergy testing or a cefazolin test dose should be considered before administering non-cefazolin alternatives.

Preoperative dental screening can reduce periprosthetic infections of hip and knee endoprostheses in the first month after surgery: results of a cohort study.

The oral cavity and, in particular, potential oral foci might pose a risk of periprosthetic joint infection (PJI). The aim of this cohort study was to determine whether practical preoperative dental screening would reduce the prevalence of early PJI in the first month after surgery. Patients attending a specialized endoprosthesis implantation clinic between 2018 and 2022 were recruited. Two groups were examined. The test group consisted of patients attending the clinic between 2020 and 2022 and who were referred to their family dentist using a standardized form. The comparison group consisted of patients who were treated in the clinic between 2018 and 2020. They were not referred to their family dentist. The two groups were compared for the prevalence of PJI. Univariate analysis followed by multiple logistic regression was performed to confirm risk factors for PJI in this cohort. 2560 individuals (test group: 1227, comparison group: 1333) were included. The prevalence of PJI was significantly lower in the test group (0.8% vs. 1.8%, p = 0.04). Multiple logistic regression with PJI as the dependent variable showed that a dental referral was a strong predictor of a lower prevalence of PJI (OR: 0.43, CI95 0.205-0.917, p = 0.03). Male gender was also strongly associated with a higher frequency of PJI (OR: 2.68, CI95 1.32-5.42, p = 0.01). Age (OR: 1.06, CI95 1.01-1.10, p = 0.01) and BMI (OR: 1.11, CI95 1.05-1.17, p < 0.01) had little effect on the risk of PJI. Dental referral using a standardized form can reduce the prevalence of early PJI. Accordingly, orthopedists and dentists should collaborate in this practical way.

308. Injectable Scaffold-based Vaccination For Prevention of Periprosthetic Joint Infection

Abstract Background There are currently no vaccines available to prevent periprosthetic joint infection (PJI) and existing vaccine platforms have failed against Staphylococcus aureus in clinical trials. We have developed a novel injectable scaffold-based vaccine for PJI. In this study, we evaluated vaccine immune response and bacterial burden in a murine model of PJI. Methods Vaccines consisting of mesoporous silica rods (scaffold) and demethylated CpG (adjuvant) were prepared using S. aureus-derived pathogen-associated molecular patterns (PAMPs) as described previously (Super and Doherty et al., Nat Biomed Eng 2022). Mice were either unvaccinated or vaccinated by subcutaneous scaffold injection containing different amounts of PAMP antigen: 7.5, 30, or 150 units (n=5-8 per group). Mice received a second scaffold injection on Day 14 (same dose as Day 0) as booster. Sera was collected on Day 28. For a challenge study, mice vaccinated on Days 0 and 14 with scaffold loaded with 30 U of PAMPs (“Vaccinated”) underwent implantation of a stainless-steel wire in the distal femur protruding into the joint space on Day 35 (n=8). The implant was inoculated with 1000 CFU S. aureus Xen29, a bioluminescent strain. Infected mice without vaccination (“Unvaccinated”) and without infection (“Uninfected”) also underwent implant insertion (n=5). Mice underwent bioluminescent imaging, collection of sera and tissue, and euthanasia with implant harvest on Day 49. Results Vaccination increased anti-S. aureus antibodies in a dose-dependent manner. Vaccination with Xen29 PAMPs resulted in antibodies with cross-reactivity against other S. aureus strains (RN4220, RN4220ΔSpa, and BAA1717). Vaccinated mice had increased CD4+ and CD8+ T cells in the adjacent draining lymph node. Vaccination induced higher IgG1 and IgG2b whereas infection only increased IgG2b (Fig. 1A). Vaccinated animals had bioluminescent similar to uninfected animals by Day 45 (Fig. 1B). Vaccinated animals had significantly less implant bacteria than unvaccinated animals and 25% of vaccinated animals did not have any detectable bacteria at euthanasia (Fig. 1C).Figure 1.A) Anti-S. aureus immunoglobulins pre- (Day 28) and post-infection (Day 49). B) Representative bioluminescent images at Day 42 and quantification. C) Implant bacterial burden at euthanasia (Day 49). * = p&amp;lt;0.05. Conclusion Scaffold-based vaccination increased generalized anti-S. aureus antibody production in an antigen dose-dependent manner and decreased bacterial burden in a murine model of PJI. Disclosures David Mooney, Ph.D., Advanced Healthcare Materials: Board Member|Agnovos: Stocks/Bonds|Attivare: Stocks/Bonds|Boston Scientific: Advisor/Consultant|Cartesian Therapeutics: Advisor/Consultant|IVIVA: Stocks/Bonds|Johnson &amp; Johnson: Advisor/Consultant|Journal of Biomedical Materials Research: Board Member|Lightning Bio: Stocks/Bonds|Lyell: Stocks/Bonds|Medicenna: Advisor/Consultant|Norvartis: Advisor/Consultant|Norvartis: Grant/Research Support|Norvartis: IP Royalties|Revela: Stocks/Bonds|Samyang: Advisor/Consultant

Mechanically stable rifampin antibiotic cement inhibits Pseudomonas aeruginosa biofilm surface growth.

Rifampin has been proven to be effective in the treatment of prosthetic infections due to its ability to intercalate into biofilms. The use of rifampin in antibiotic spacers is not well described, which would be especially important in the local periprosthetic environment where parenteral doses have poor penetration. The null hypothesis tests if rifampin use in polymethyl methacrylate (PMMA) cement will show no clinically significant impact on mechanical strength at antibiotic concentrations that remain bactericidal. Test antibiotic cement samples supplemented with 0, 30, 50, 100, 150, or 200 mg of rifampin into a standard 40 g bag were tested for compression to failure using published ASTM standards. The samples were then inoculated with Pseudomonas aeruginosa and either evaluated for lipopolysaccharide (LPS) presence as a marker of biofilm or tested by elution as the Kirby Bauer assay. Rifampin concentrations of 30 and 50 mg, showed no statistically different mechanical characteristics from control PMMA (p > 0.05). The 100-mg sample fell within the acceptable range of compressive strength and had significantly less LPS and bacterial presence compared to the control at 12 and 24 h. The ability of PMMA with 100 mg of rifampin to maintain its structural integrity and have significant bacterial inhibition at 12 and 24 h makes it a great candidate as an antibiotic bone cement additive. PMMA loaded with up to 100 mg of rifampin shows promise in the treatment and prevention of periprosthetic joint infection for total knee and total hip arthroplasty.

The Intraoperative Use of Defensive Antibacterial Coating (DAC®) in the Form of a Gel to Prevent Peri-Implant Infections in Orthopaedic Surgery: A Clinical Narrative Review.

Periprosthetic joint infections (PJIs) in arthroplasty and osteosynthesis-associated infections (OAIs) in reconstructive surgery still represent a challenging complication in orthopaedics and traumatology causing a burden worsening the patient's quality of life, for caregiver and treating physicians, and for healthcare systems. PJIs and OAIs are the result of bacterial adhesion over an implant surface with subsequent biofilm formation. Therefore, the clinical pathological outcome is a difficult-to-eradicate persistent infection. Strategies to treat PJIs and OAIs involve debridement, the replacement of internal fixators or articular prostheses, and intravenous antibiotics. However, long treatments and surgical revision cause discomfort for patients; hence, the prevention of PJIs and OAIs represents a higher priority than treatment. Local antibiotic treatments through coating-release systems are becoming a smart approach to prevent this complication. Hydrophilic coatings, loaded with antibiotics, simultaneously provide a barrier effect against bacterial adhesion and allow for the local delivery of an antibiotic. The intraoperative use of a hyaluronan (HY)-derivative coating in the form of a gel, loaded with antibiotics to prevent PJI, has recently raised interest in orthopaedics. Current evidence supports the use of this coating in the prophylaxis of PJI and IRIs in terms of clinical outcomes and infection reduction. Thus, the purpose of this narrative review is to assess the use of a commercially available HY derivative in the form of a gel, highlighting the characteristics of this biomaterial, which makes it attractive for the management of PJIs and IRIs in orthopaedics and traumatology.

Cost-Effectiveness of Bone Cement With and Without Antibiotics: A Broader Perspective

Background Periprosthetic joint infections (PJIs) and periprosthetic femur fractures (PFFs) increase total costs of care. Retrospective registry/institutional studies with selection bias and underpowered meta-analyses have corrupted the evidence base regarding antibiotic-laden bone cement (ALBC) use in total knee arthroplasties (TKAs). Clinical practice guidelines (CPGs) recommend using cement fixation of femoral components in hip fracture patients to prevent PFFs, but have no recommendations regarding ALBC. Hip osteoarthritis CPGs have no bone cement recommendations regarding prevention of PJIs or PFFs. ALBC is potentially cost-effective by reducing PJIs, PFFs, and reducing implant costs. Methods A systematic review was conducted to identify randomized controlled trials (RCTs), meta-analyses, and registry reports related to the efficacy of ALBC in reducing PJIs and cemented femoral fixation in reducing PFFs. Numbers needed to treat (NNT) are calculated. Cost-effectiveness margins per case are calculated. Results A pooled analysis of four TKA RCTs found ALBC reduces PJI by 0.94% (p=0.027), NNT 106. A total hip arthroplasty (THA) meta-analysis found ALBC reduces PJI by 0.58% (p&lt;0.0001), NNT 172. A hip hemiarthroplasty (HH) RCT found high-dose dual-antibiotic ALBC reduces PJI by 2.35% (p=0.0474), NNT 43. A THA registry report found that cemented fixation compared to ingrowth fixation reduced PFFs by 0.44% (p&lt;0.0001), NNT 229. A pooled analysis of three HH RCTs found that cemented femoral stem fixation reduced PFFs by 5.09% (p-0.0099), NNT 20. Mean PJI treatment costs are $80,000. Mean PFF treatment costs are $27,596. Mean HH cemented femoral stem cost reduction: $685. Using ALBC: TKA margin/case is $755; THA margin/case is $586; and HH margin/case is $3,925. Using plain bone cement: TKA margin/case is $0; THA margin/case is $121; and HH margin/case is $2,065. Conclusions A broader perspective demonstrates that ALBC provides significant financial margins in TKAs, THAs, and hip hemiarthroplasties. ALBC is cost-effective when including the additional costs of using ALBC in TKAs, THAs, and hip hemiarthroplasties. Hand-mixed ALBC is more cost-effective than pre-mixed ALBC in all scenarios.

Oral Health Screening for Risk Reduction for Early Periprosthetic Joint Infections of Hip and Knee Endoprostheses—Results of a Prospective Cohort Study

This prospective observational study had two aims: (I) to assess whether a preoperative dental screening before endoprosthesis (EP) implantation with need-based dental intervention would decrease the prevalence of periprosthetic joint infection (PJI) and (II) to evaluate whether instructed orthopedic surgeons would achieve similar results in oral screening as dentists. The preoperative oral health statuses of the patients, prior to EP insertion, were either evaluated by the patients’ general dentists (Ia) or, if the patient had not visited a general dentist, by an instructed orthopedic surgeon (Ib). Both the dentist and orthopedic surgeon used standardized risk estimation (low risk, moderate risk, and high risk) for an oral-health-related infectious complication after EP insertion, including a recommendation for further management of the patient. If required, a need-based dental rehabilitation was performed. In addition, retrospective data evaluation of a comparison group (II) was performed, which had not been screened orally preoperatively. A total of 777 patients (screening group (I): n = 402, of which 229 were screened by a dentist (Ia), 173 were screened by an orthopedic surgeon (Ib); comparison group (II): n = 375) were included. No general association between early infection rate and preoperative oral screening in general was found (1% PJI in screening group (I), 1.6% PJI in comparison group (II); p = 0.455). However, screening performance (dentist vs. orthopedic surgeon) had a significant impact on the prevalence of developed PJIs (p = 0.021). Thereby, 100% of observed infections in the screening group (I) occurred in the group with previous oral screening by an orthopedic surgeon (Ib). Furthermore, the C-reactive protein (CRP) value at discharge was significantly lower when general preoperative oral screening had been performed (group I vs. group II, p = 0.03). Only preoperative oral screening by a dentist had the potential to reduce oral-focus-associated EP infections; therefore, increased attention should be paid to the further promotion of interdisciplinary work between dentists and orthopedic surgeons. Dental screenings, using objectifiable criteria, as applied in this study, seem reasonable but require further validation in larger cohorts.

Tranexamic acid administration for the prevention of periprosthetic joint infection and surgical site infection: a systematic review and meta-analysis.

Tranexamic acid (TXA) has been widely utilized to reduce blood loss and allogeneic transfusions in patients who undergo lower limb arthroplasty. In recent years, there have been several articles reporting the incidence of periprosthetic joint infection (PJI) as a primary outcome of TXA administration, but no meta-analysis has been conducted to date. The present systematic review and meta-analysis evaluated the efficacy of TXA administration in preventing PJI and surgical site infection (SSI). Pubmed, CINAHL, and the Cochrane Library bibliographic databases were searched for studies published by May 24, 2022, that evaluated the effects of TXA on PJI and SSI. Two researchers screened the identified studies based on the PRISMA flow diagram. The quality of each randomized clinical trial was assessed using Version 2 of the Cochrane risk-of-bias tool for randomized trials (ROB2.0), and the quality of cohort and case-control studies was assessed by risk of bias for nonrandomized studies (ROBANS-I). Of the 2259 articles identified from the database search, 31 were screened and selected. Treatment with TXA significantly reduced the incidence of overall infection, including PJI, SSI, and other infections (OR 0.55; 95% CI 0.49-0.62) (P < 0.00001), and that of PJI alone (OR 0.53; 95% CI 0.47-0.59) (P < 0.00001). TXA reduced the incidence of overall infection in patients who underwent total hip arthroplasty (THA; OR 0.51; 95% CI: 0.35-0.75) (P = 0.0005) and total knee arthroplasty (TKA; OR 0.55; 95% CI: 0.43-0.71) (P < 0.00001). Intravenous administration of TXA reduced the incidence of overall infection (OR 0.59; 95% CI 0.47-0.75) (P < 0.0001), whereas topical administration did not. Intravenous administration of TXA reduces the incidence of overall infection in patients undergoing both THA and TKA. Level III.

What's New in Musculoskeletal Infection.

What's New in Musculoskeletal Infection.

Electrophoretic deposition of gentamicin and chitosan into titanium nanotubes to target periprosthetic joint infection.

Periprosthetic joint infection (PJI) occurs in 1%-2% of primary total hip and knee arthroplasties; the rate can reach 20% in individuals at risk. Due to the low local bioavailability of systemic antibiotics and possible off-target effects, localized drug delivery systems are of great importance. Our aim was the electrophoretic deposition (EPD) of gentamicin and chitosan in Titanium (Ti) nanotubes to establish a local, prolonged antibiotic delivery. Nanotubes were created on Ti wire with a two-step anodization process. For drug deposition, EPD and the air-dry methods were compared. For a prolonged drug release, gentamicin and crosslinked chitosan were deposited in a two-step EPD process. Drug release was quantified by fractional volume sampling. The Ti wires were tested against Staphylococcus aureus by agar dilution and liquid culture methods. MC3T3-E1 osteoblastic cell viability was determined with trypan blue. Nanotubes were characterized by a 100 nm diameter and 7 μm length. EPD allowed a higher amount of gentamicin deposited than the air-dry method. Drug deposition was controllable by adjusting the voltage and duration of the EPD process. The crosslinked chitosan layer allowed diffusion-driven release kinetics for up to 3 days. Gentamicin-loaded Ti wires significantly inhibited bacterial growth and resulted in a larger inhibition zone compared to unloaded wires. Twenty-four hours of incubation with loaded wires did not have a significant effect on osteoblast viability. Gentamicin-loaded Ti nanotubes represent a promising approach for PJI prevention, as well as a valuable preclinical tool for the investigation of localized drug delivery systems created on Ti surface.

Application of the Mayo Periprosthetic Joint Infection Risk Score for Total Ankle Arthroplasty.

Assessing patient's risk of infection is fundamental for prevention of periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA). The Mayo Prosthetic Joint Infection Risk Score (Mayo Score) is based on data from total hip and knee arthroplasty and has not been validated for application for TAA. A total of 405 consecutive TAA cases were followed for 6 months for PJI. Individual patients' Mayo Scores were calculated and analyzed with logistic regression and receiver operating characteristic (ROC) for predictability for PJI. A critical cut-off Mayo Score for patients at high risk of PJI was determined by best Youden index. Among the Mayo Score-defined high-risk patients, the contribution of different risk factors were compared between the PJI and non-PJI patients. There were 10 cases of PJI (2.5%) among the 405 cases within 6 months after TAA. Of the 405 patients, the Mayo Scores ranged between -4 and 13 (median 2; interquartile range 0-5). The average Mayo Score was 2.5 ± 3.4 in the non-PJI patients and 7.7 ± 3.1 in the PJI patients (P < .001). Logistic regression showed that the probability of PJI increased with higher Mayo Scores (odds ratio 1.48, 95% CI 1.23-1.78). All but 1 PJI patients had a Mayo Score >5. The sensitivity and specificity were 90.0% and 84.3%, respectively, when a Mayo Score >5 was used as a criterion for high risk of PJI. This study demonstrated that the Mayo Score could similarly predict PJI risk after TAA as in total hip and knee arthroplasty. Data analysis suggests that a Mayo Score >5 could be a criterion for identifying high-risk patients for PJI, although further validation with a large number of PJI cases is necessary. Level II, developing diagnositic criteria with consecutive cases.