Rate Of Periprosthetic Joint Infection Research Articles

Effect of oral antibiotics after two-stage revision for periprosthetic joint infection on subsequent antibiotic resistance within a national cohort of United States veterans

Abstract. Background: Prior studies have indicated that administration of prolonged courses of oral antibiotics after Stage 2 reimplantation surgery for periprosthetic joint infection (PJI) results in a lower rate of recurrent PJI. However, there is concern that this antibiotic usage results in an increased risk of antibiotic resistance in any subsequent PJI that does occur. Methods: We retrospectively reviewed patients who underwent Stage 2 reimplantation surgery for PJI within the national Veterans Affairs hospital system of the United States. We compared those who received at least 2 weeks of oral antibiotics after Stage 2 reimplantation to those who did not. The primary outcome was the proportion of organisms resistant to four classes of antibiotics (tetracyclines, fluoroquinolones, oral beta-lactams, and sulfonamides) in recurrent PJI. Secondary outcomes included recurrent PJI and death. Results: Of the 605 patients who underwent Stage 2 reimplantation for PJI, 154 patients received at least 14 d of antibiotics after surgery and 451 patients did not. Bacteria causing recurrent PJI in patients who received prolonged antibiotics were more likely to be resistant to tetracyclines and trimethoprim–sulfamethoxazole but not oral beta-lactams or fluoroquinolones. There was no difference in risk of recurrent PJI or death between the two groups. Conclusions: Prolonged oral antibiotic treatment after Stage 2 reimplantation increases the risk of antibiotic resistance to some antibiotics in subsequent PJI. We recommend further research to identify the best choice of antibiotic and duration after Stage 2 reimplantation, to maximize benefits while minimizing risks.

Safety and efficacy of combined intra-articular administration of vancomycin and ε-aminocaproic acid in total hip arthroplasty : a clinical study.

To evaluate the concurrent use of vancomycin and ε-aminocaproic acid (EACA) in primary total hip arthroplasty (THA). In total, 120 patients undergoing unilateral primary THA were divided into three groups: Group VE received intra-articular vancomycin and EACA; Group V received only intra-articular vancomycin; and Group E received only intra-articular EACA. Blood and joint fluids were sampled postoperatively to measure the vancomycin levels using chromatography. Blood loss and kidney function were monitored. Groups E and VE had equivalent blood loss, which was less than that in Group V. Intra-articular vancomycin levels were higher in Group VE at all intervals, with similar serum levels across the groups. Acute kidney injury, ototoxicity, and allergies were not observed, nor was a difference in rates of periprosthetic joint infection. Adding intra-articular EACA to vancomycin did not affect intra-articular vancomycin levels, and maintained EACA's antifibrinolytic effects.

Radiographic soft tissue thickness is not a risk factor for infection after primary total ankle arthroplasty.

As the incidence of total ankle arthroplasty (TAA) for the management of end-stage arthritis is on the rise, identification of risk factors for periprosthetic joint infection (PJI) is essential. There has been limited research exploring the use of radiographic soft tissue thickness in TAA despite its predictive value in other forms of arthroplasty. This study evaluated the predictive capabilities of radiographic soft-tissue thickness for PJI following TAA. A retrospective analysis of 323 patients at a single institution who underwent primary TAA from 2003 to 2019 was conducted. Patient demographics, comorbidities, indication for surgery, prosthesis type and tourniquet time were recorded. Tibial-Tissue and Talus-Tissue distances were measured on preoperative lateral radiographic imaging. Logistic regression was utilized to determine the Odds Ratio (OR) of risk factors for the occurrence of PJI. Of the 323 patients, 6 patients (1.86 %) developed a PJI. Average duration of follow-up was 8.42 ± 2.52 years. Neither Tibial-Tissue (OR = 0.975; 95 % CI [0.947 - 1.004]; p = 0.09) nor Talus-Tissue thickness (OR = 0.976; 95 % CI [0.940 - 1.012]; p = 0.18) were significant predictors of PJI. Although not statistically significant, the infected cohort had smaller average Tibial-Tissue (2.20 vs. 2.53 cm; p = 0.05) and Talus-Tissue thickness (2.19 vs. 2.44 cm; p = 0.36) compared to the non-infected cohort. Measurements such as Tibial-Tissue length and Talus-Tissue length were not significant predictors of PJI following primary TAA. These findings underscore the necessity for additional research to identify modifiable risk factors aimed at reducing PJI rates and enhancing patient outcomes. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

Risk of Postoperative Infection in Total Knee Arthroplasty Patients with Preoperative Methicillin-Resistant Staphylococcus aureus (MRSA) Colonization

Background/Objectives: While methicillin-resistant Staphylococcus aureus (MRSA) colonization is a known risk factor for surgical site infections, no definitive recommendations exist regarding preoperative S. aureus screening and decolonization protocols due to inconclusive evidence in Orthopedic Surgery. This study aimed to examine the correlation between preoperative MRSA colonization and postoperative infections in Total Knee Arthroplasty (TKA) patients. Methods: Data from 2005 to 2023 were collected from TriNetX, a global health research network, reviewing 237,360 unique patients. TKA patients were assigned under Current Procedural Terminology, while International Statistical Classification of Diseases Codes were used to identify preoperative comorbidities and postoperative complications. Demographic and analytical statistics were compared between MRSA-positive and control groups before and after propensity matching. Results: The MRSA-positive group had a significantly (p < 0.001) higher proportion of patients over 65 years (47.17% vs. 38.46%), obesity (41.76% vs. 34.67%), smoking disorders (33.36% vs. 19.73%), and diabetes (25.06% vs. 19.85%) compared to the control group. Postoperative complications were significantly (p < 0.001) more frequent in the MRSA-positive group, specifically periprosthetic joint infection (PJI) (4.11% vs. 0.79%, OR = 5.40), deep (0.12% vs. 0.01%, OR = 11.15) and superficial (0.37% vs. 0.09%, OR = 4.17) surgical site infections, and wound dehiscence (1.11% vs. 0.52%, OR = 2.13). The matched analysis confirmed significantly (p < 0.001) higher rates of PJI (4.39% vs. 1.18%, OR = 3.59). Conclusions: Our results illustrated preoperative colonization of MRSA as associated with an increased risk of wound-related complications. Surgeons and patients must consider preoperative MRSA colonization status when deciding if TKA is an optimal treatment option.

Intraoperative Femoral Fractures During Primary Total Hip Arthroplasty Are Associated With Increased Revision and Complication Rates.

Intraoperative femoral fractures are a rare, but serious complication of primary total hip arthroplasty (THA), and little is known about the rates of complications and reoperations in these patients. The objective of this investigation was to describe the two-year outcomes and revision rates in patients who sustain an intraoperative femoral fracture during THA. A large administrative claims database was queried for patients who sustained an intraoperative femoral fracture during primary and elective THA from 2015 to 2022. Patients requiring THA for tumors or fractures were excluded. Patients who sustained an intraoperative fracture were matched 1:1 based on age, sex, and comorbidity burden. The incidence of medical and surgical complications was compared between cohorts. Kaplan-Meier and multivariate analyses were used to compare two-year outcomes between groups. Among matched cohorts of 2,795 patients, those who sustained an intraoperative femoral fracture experienced higher rates of periprosthetic joint infection (PJI) (odds ratio [OR]: 2.0, P < 0.001), instability (OR: 1.6, P= 0.013), revision THA (OR: 2.7, P < 0.001), deep vein thrombosis (OR: 3.0, P < 0.001), and transfusion (OR: 2.8, P < 0.001) at 90 days and demonstrated significantly longer length of stay (5.7 ± 6.3 versus 3.6 ± 4.5 days, P < 0.001). At a 2-year follow-up, patients who had an intraoperative femoral fracture were more likely to develop a PJI (OR: 2.1, P < 0.001), periprosthetic fracture (OR: 1.6, P= 0.030), aseptic loosening (OR: 3.0, P < 0.001), and instability (OR: 1.7, P= 0.001) and undergo all-cause revision (OR: 2.3, P < 0.001). Patients who sustained an intraoperative femoral fracture during primary THA were significantly more likely to develop PJI, periprosthetic fracture, aseptic loosening, instability, undergo revision THA, and experience medical complications. Strategies to mitigate intraoperative fracture during THA are necessary to improve outcomes in these high-risk patients.

The Efficacy and Safety of Prophylactic Treatment Methods for Cutibacterium Acnes Infection in the Shoulder: A Systematic Review of Level of Evidence I Randomized Controlled Trials.

Cutibacterium acnes (C. acnes), formerly Propionibacterium acnes (P. acnes), is the most common pathogen responsible for postoperative shoulder infections. Prevention of shoulder infection is crucial to improving patient outcomes, prolonging implant longevity, and reducing costs. The purpose of this study is to evaluate the effectiveness of various prophylactic treatments for C. acnes in the shoulder. A systematic review of 15 randomized controlled trials was conducted to evaluate the effectiveness of various skin preparation methods in the reduction of C. acnes for patients undergoing shoulder surgery. Three electronic databases were queried as follows: PubMed, Embase, and the Cochrane Library databases. Data extraction for this study was performed by three independent reviewers, and only level I studies were included. Outcomes were assessed based on the effectiveness of the method used; side effects were also analyzed. Fifteen studies were included in this review. Seven studies utilized a regimen of at-home treatment in the days leading up to culture sampling, while the other eight studies administered treatment just prior to sampling. Seven studies found their respective treatment methods to be statistically significant. No preparation methods applied immediately prior to sampling showed conclusive superiority. The application benzoyl peroxide in the days prior to sampling showed significantly lower rates of colonization when compared to control groups in five separate studies. There remains no consensus on the optimal skin preparation method immediately prior to surgery, however, acne cream applied in the days leading up to surgery has been shown to significantly reduce the bacterial load of C. acnes. While BPO appears to be the superior method of prophylactic treatment, it is also associated with higher rates of complications and skin reactions following treatment; thus, caution is warranted. Further studies should investigate whether this reduction in bacterial load translates to meaningfully lower rates of periprosthetic joint infections.

Safety of perioperative intravenous different doses of dexamethasone in primary total joint arthroplasty: a retrospective large-scale cohort study

PurposePerioperative intravenous different doses of dexamethasone (DEX) can realize effective clinical outcomes in total joint arthroplasty (TJA). However, the effect of different DEX doses on readmission rates and postoperative complications remains unclear.MethodsWe retrospectively analyzed patients who underwent primary TJA between December 2012 and October 2020. Patients were categorized into three groups based on the total perioperative dose of DEX: control group (DEX = 0 mg), low-dose group (DEX < 15 mg), and high-dose group (DEX ≥ 15 mg). Primary outcomes included 30-day and 90-day readmission rates. Secondary outcomes included the rates of periprosthetic joint infection (PJI) and wound complications, with treatment outcomes for these complications were also evaluated. Multivariable analysis was used to identify risk factors for readmission.ResultsA total of 14,557 procedures were included, with 6,686 in the control group, 4,325 in the low-dose group, and 3,546 in the high-dose group. No significant differences were observed among the groups for 30-day (p = 0.645) or 90-day readmission rates (p = 0.539). Additionally, there were no significant differences in rates of PJI (p = 0.401) or wound complications (p = 0.079). Treatment for PJI and wound complications was successful across all groups. Risk factors for 30-day readmission included age > 80 years (OR: 2.585, 95% CI: 1.123–5.954, p = 0.026) and undergoing total hip arthroplasty (THA) (OR: 1.692, 95% CI: 1.137–2.518, p = 0.009). For 90-day readmission, age 71–80 years (OR: 2.199, 95% CI: 1.349–3.583, p = 0.002), age > 80 years (OR: 3.897, 95% CI: 1.966–7.727, p < 0.001), and THA (OR: 1.622, 95% CI: 1.179–2.230, p = 0.003) were significant risk factors. However, neither low-dose nor high-dose DEX was associated with increased 30-day or 90-day readmission rates.ConclusionsPerioperative intravenous DEX may be not associated with the readmission, PJI, and wound complications in patients undergoing primary TJA.

Tissue adhesive for wound closure, as adjunct to staples, reduces postoperative wound drainage after total knee arthroplasty.

Wound drainage after total knee or hip arthroplasty is a relatively frequent complication. It results in delayed mobilization, prolonged hospital stay, increased costs and is associated with an increased risk of infection. In this study, tissue adhesive was administered as an adjunct to skin closure with staples. From February 2017, in a cohort of 1000 consecutive patients receiving primary total hip, total knee (TKA) or unicondylar knee arthroplasty, tissue adhesive was administered after skin closure with staples. Patients were prospectively analyzed for increased duration of hospital admission due to wound drainage. This cohort was compared to a consecutive cohort of 1000 patients before February 2017, treated with the same perioperative protocol, except for administration of tissue adhesive for skin closure. Difference in number of patients requiring prolonged hospital stay due to wound drainage was assessed between the two cohorts. Besides, costs of tissue adhesive were compared to change in hospital admission costs to assess the cost-effectiveness. The number of patients requiring prolonged hospital admission due to wound drainage was significantly reduced in the study group compared to the group not treated with tissue adhesive (39/990 patients vs. 68/961 patients, p = 0.002). The mean number of extra days of hospital admission due to wound drainage was also significantly lower in the tissue adhesive cohort (0.06 vs. 0.13 days). The mean number of extra days in hospital only proved to be significant in the TKA cohort. Total money saved by preventing prolonged hospital admission in general cohort amounted €19,610. This study proves that tissue adhesive as an adjunct to staples for wound closure after total knee arthroplasty reduces wound drainage and is cost effective. Besides, this could potentially lead to lower rates of periprosthetic joint infection. Therefore, the use of tissue adhesive in total knee arthroplasty would be recommended.

Use of Oral and Intravenous Tranexamic Acid in Total Knee Arthroplasty and Total Hip Arthroplasty Procedures.

Tranexamic acid (TXA) is an antifibrinolytic drug commonly used in total knee arthroplasty (TKA). Intravenous (IV) and topical TXA therapy have been extensively studied and shown to reduce blood loss, length of hospital stay, and blood transfusion rates following TKA. Despite the extensive literature regarding IV and topical TXA in orthopedics, there is a current dearth of studies analyzing oral usage. The primary purpose of this randomized controlled study is to compare post-surgical blood loss with the use of IV and oral TXA following a TKA. In this multicenter, prospective, controlled, randomized study, patients were randomized to receive 1.95 grams of oral TXA two hours preoperatively or 15 mg/kg (1 gram max) of IV TXA mixed in 100 mL of normal saline preoperatively. Intraoperatively, each patient received a combination of 500 mg TXA mixed with 25 mL of normal saline injected into the suction drain and clamped for 30 minutes postoperatively. The primary outcome was absolute (g/dL) change in hemoglobin levels at 24 hours postoperatively. Secondary outcomes included a percent change in hematocrit levels and total drain output at 24 hours postoperatively. Power analysis determined that 40 patients were required in each group. About 24 patients received IV TXA and 14 patients received oral TXA. The mean decrease in hemoglobin 24 hours postoperatively was not greater (p=0.12) with the use of oral TXA compared to IV TXA (1.70 g/dL vs. 2.50 g/dL, respectively). The mean decrease in hematocrit 24 hours postoperatively in the treatment (oral TXA) group was not greater (p=0.18) than the control (IV TXA) group (5.3% vs. 7.0%, respectively). Both changes in hemoglobin and hematocrit resulted in a normal distribution of data and satisfactory one-sided T-test values (p=0.98 and p=0.92, respectively). The mean drain output measured 24 hours postoperatively in the treatment group was significantly (p=0.04) less than the control group (47.5 mL vs. 170 mL, respectively). All tests performed were one-sided T-tests. Compared to IV TXA, we found oral administration to have no significant difference in hemoglobin (p=0.12) or hematocrit (p=0.18) loss. These findings may support the utilization of oral TXA as a valid alternative to the IV route. We found that patients who received oral TXA produced significantly lower drainage output when compared to IV (47.5 mL and 170 mL, respectively; p=0.04). Persistent wound drainage following TKA has been correlated with increased rates of periprosthetic joint infections, residual pain, and reoperation. Further work is needed to assess the effect of postoperative drainage quantity on the recovery of TKA. Based upon the data gathered, oral TXA does not result in greater loss of hemoglobin or hematocrit within 24 hours following surgery. However, total drain output was significantly less in the oral group after 24 hours following a TKA. With more subjects, we would expect to see the mean values between groups move closer to each other and fit well with the current literature. This suggests that oral TXA is non-inferior to IV TXA when comparing these variables following TKA. Our current study has limitations, including a small sample size and no blinding. Therefore, this study provided a limited quality of evidence. Confirmation with a blinded, randomized controlled trial and meta-analysis is required to report a higher quality of evidence.

Increasing Utilization of Extended Oral Antibiotic Prophylaxis Following Total Knee Arthroplasty from 2010 to 2022

Extended oral antibiotic (EOA) prophylaxis has been shown to reduce rates of periprosthetic joint infection in high-risk patients following total knee arthroplasty (TKA). Although national societies' recommendations against their use and clinical efficacy remain controversial, the increase in the literature surrounding EOA prophylaxis suggests a potential change in practice patterns that may warrant the creation of national guidelines. The purpose of this study was to investigate the trends in the utilization of EOA prophylaxis following TKA from 2010 to2022. Patients who underwent primary or aseptic revision TKA between 2010 and 2022 were identified in a national administrative claims database. Temporal trends in EOA usage following primary or revision TKA were calculated, and secondary analysis examined rates of utilization across demographics, including patients considered at high risk for infection. In total, 1,258,759 primary and 91,530 aseptic revision TKA patients were included in this study. From 2010 to 2022, EOA prescriptions increased by 321 and 368% following primary and revision TKA, respectively. Rates of utilization among high-risk individuals were similar to those of the general population. The use of EOA prophylaxis after TKA has increased significantly since 2010. Given their increasing usage and variation in prescription patterns among patients at high risk of infection, guidelines surrounding their use are necessary to promote antibiotic stewardship while preventing rates of infection.

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

The relationship between surgeon and hospital case volumes and postoperative risk following total hip arthroplasty 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. A health care database was used to retrospectively identify all primary and elective total joint arthroplasties 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 total joint arthroplasty (THA: 37.71%; TKA: 62.29%) by low-volume surgeons (< 57 THAs and < 68 TKAs) identified and divided into high- 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. After 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%, adjusted odds ratio= 0.69 [95% confidence interval= 0.54 to 0.88], P= 0.002; TKA 0.51 versus 0.69%, adjusted odds ratio= 0.73, [95% confidence interval= 0.61 to 0.87], P= 0.007). Increasing institutional case volume may mitigate the increased risk of PJI associated with low annual surgeon case volume.

The Use of a Novel Surgical Irrigant May Be Associated with Decreased Incidence of Surgical Site Infections

Background Periprosthetic joint infection (PJI) represents a formidable challenge to patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This investigation evaluated a novel antimicrobial surgical irrigation solution, XPerience (XP) (Next Science LLC, Jacksonville, FL), with proven high &amp; persistent in-vivo efficacy against planktonic bacteria and biofilm. The primary objective of this investigation was to compare the incidence of PJI following TKA performed with use of XP versus a standard control rinse (povidone-iodine). The secondary outcome was an all-cause return to operating room (OR) rate. Methods A retrospective cohort study was conducted from 824 consecutive patients undergoing primary THA/TKA from 12/1/2019 - 11/30/2021 treated using povidone-iodine solution and 471 consecutive patients undergoing primary THA/TKA from 12/1/2021 - 12/30/2022 treated with XP at a single institution by the senior author. All surgeries in both groups followed largely identical preoperative, perioperative, and postoperative protocols. A total of 1,295 cases were analyzed. The groups shared largely analogous background characteristics pertaining to age, sex, BMI, and American Society of Anesthesiologists (ASA) class. Results The overall SSI rate was 0% (0/471) in the XP group and 0.49% (4/824) in the control group (P = 0.3). The overall return to OR rate was 0.21% (1/471) in the XP group and 0.85% (7/824) in the control group (P = 0.3). Control group cases returned to the OR for hematoma debridements, periprosthetic fracture fixation, and PJI revisions. Conclusion This investigation is the first to remark on the clinical efficacy of a novel surgical irrigant. There was no statistically significant difference in rates of PJI or return to OR with the irrigant versus without, though a trend towards lower rates was observed in the context of a low baseline infection rate. Limitations pertaining to a single-center experience and sample size may be addressed by further studies incorporating broader enrollments.

Arthroscopy Within Three Months Prior to Unicompartmental Knee Arthroplasty Is Associated With an Increased Rate of Periprosthetic Joint Infection

Arthroscopy remains a commonly performed procedure in patients who have meniscal or other osteochondral pathology prior to ultimately being indicated for unicompartmental knee arthroplasty (UKA). The purpose of this study was to examine the timing of knee arthroscopy prior to UKA and its association with 2-year periprosthetic joint infection (PJI) rates and medical and surgical complications. Patients undergoing UKA who had history of ipsilateral arthroscopy within 2 years prior to the UKA were identified in a national insurance database. A control cohort of propensity matched patients who did not have a history of arthroscopy was identified. Study cohorts were established based on timing of the arthroscopic procedure: 0 to 3, 3 to 6, 6 to12, and 12 to 24 months prior to UKA. Patients were included if they had 2-year postoperative follow-up after UKA. The 90-day rates of postoperative medical and 2-year surgical complications were recorded. Multivariate analysis was conducted to account for confounding variables and covariates. A final cohort of 3,471 patients met inclusion criteria. Patients undergoing UKA within three months of the arthroscopic procedure demonstrated a higher incidence of PJI when compared to the control cohort (3.30 versus 1.12%, P= 0.012). In addition, there was an increased rate of periprosthetic fracture observed in those undergoing UKA within three months of arthroscopy when compared to the control (1.10 versus 0.20%, P= 0.010). Patients undergoing ipsilateral arthroscopy within three months of a UKA demonstrated a nearly 3-fold increased incidence of PJI when compared to the control. There was no increased incidence of PJI when UKA was staged greater than three months after arthroscopy. These findings provide insight for preoperative considerations for arthroplasty surgeons in this patient population. Level III, retrospective comparative study.

Prevalence of unexpected intraoperative cultures (UPIC) in revision total knee arthroplasty (TKA) and risk of periprosthetic joint infection (PJI).

Prevalence of unexpected positive intraoperative cultures (UPIC) in revision total knee arthroplasty (TKA) is reported to be 8.32% with largely varying findings in individual studies (5.92-62.07%) due to a heterogeneity in preoperative diagnostic work-up and diagnostic criteria for periprosthetic joint infection (PJI). When diagnosed as unsuspected PJI, re-revision rate is reported to be as high as 18.45% compared to 2.94% in patients with UPIC classified as contamination (p = 0.0237). We performed a monocentric retrospective analysis of revision TKA surgery to determine prevalence of UPIC, risk of developing a subsequent PJI and re-revision rate after 24 months compared to those without UPIC. All presumed aseptic total knee revision procedures from 2008 until 2017 were retrospectively reviewed. Single stage femorotibial revisions of TKA with at least 3 intraoperative cultures and a minimum follow-up of 24 months were included, whereas partial revisions or revisions from unicompartimental knee prosthesis to TKA were excluded. Demographic data were collected as well as initial reason for revision, preoperative aspiration results, micro-organism identified and postoperative antibiotics' administration. Primary outcome was survival rate after 24 months with differentiation based on UPIC interpretation: sterile, contamination, unsuspected PJI. Of 256 included cases, 75 (29.3%) were found to have at least 1 UPIC during revision surgery, 72% of whom a single UPIC was found. Thirty-four cases (13.28%) were interpreted as unsuspected PJI and therefore treated with antibiotics. In total, 13 of the 256 patients (5.08%) had to be re-revised during follow-up with 7 PJI (2.73%), none of them developing reinfection defined as PJI with the same microorganism. A statistically significant trend towards earlier failure in the unsuspected PJI group compared to the contaminant group was not observed. However, a higher incidence of re-revisions attributed to septic reasons was noted in the former group. Presence of UPIC in presumed aseptic revision TKA does not correlate with a lower survival rate, but a higher incidence of subsequent PJI was observed in cases interpreted as unsuspected PJI.

Perioperative Glycemic Variability Influences Infection Rates Differently Following Revision Hip and Knee Arthroplasty

Recent investigations have determined that abnormal postoperative glycemia following primary total joint arthroplasty is associated with adverse events. Our study aimed to determine if hyperglycemia and glycemic variability following aseptic revision total joint arthroplasty were associated with periprosthetic joint infection (PJI) within two years postoperatively. A retrospective review was performed of 2,208 patients within a single institution undergoing aseptic revision total joint arthroplasty from 2012 to 2019. Postoperative glucose values were recorded. Glycemic variability was measured via three parameters: coefficient of variation, mean amplitude of glycemic excursions, and J-index. Logistic regression analyses were performed to examine associations with PJI at 90-day, 1-, and 2-year follow-up. In revision hips, all glycemic measures were not associated with PJI at any time point in logistic regression analyses, except for the mean amplitude of glycemic excursions, which predicted PJI at one year (P= 0.045); body mass index was the only factor associated with PJI at all timepoints in all models. In revision knees, all glycemic measures were not associated with PJI at any timepoint in logistic regression analyses; however, PJI rates differed between diabetics and nondiabetics at all time points (P<0.05). Our findings illustrate that decreasing preoperative body mass index and postoperative glycemic variability may be critical in reducing PJI rates in revision hips. Furthermore, patients who have diabetes should be counseled that they remain at higher risk of PJI regardless of perioperative glucose control after revision knee surgery.

Intraosseous regional antibiotic prophylaxis in total joint arthroplasty (TJA): Systematic review and meta-analysis

A major catastrophic adverse event after total joint arthroplasty surgery (TJA) is the periprosthetic joint infection (PJI). In the recent years, regional antibiotic prophylaxis has gained momentum as a novel infection control strategy in total knee arthroplasty (TKA), with different purported benefits over systemic administration. The current article was planned to comprehensively review the available evidence in literature; as well as compare the safety and effectiveness of intraosseous (IO) antibiotic prophylaxis with systemic prophylaxis in patients undergoing TJA. An independent database (5 databases: Pubmed, Scopus, Embase, Web of science and Cochrane library) search was performed (on January 1, 2024) using suitable key words [PROSPERO (registration number: CRD42023458219)]. All randomised controlled trials (RCT), prospective or retrospective studies reporting data on intraosseous vancomycin or other antibiotics during arthroplasty for prophylaxis of PJI were considered. Studies not pertaining to the topic of interest or non-clinical trials were excluded. The evaluated outcome parameters included PJI incidence, systemic antibiotic levels, minimal inhibitory concentrations, local antibiotic concentrations achieved in soft tissues (or fat) and bone; and associated complications. While the "risk of bias" was evaluated using ROB-2 tool and MINORS criteria; LibreOffice version (v)7.5.6 was utilized for data management. OpenMeta-analyst v5.26.14 and RevMan v5.4 software were employed for meta-analysis. Following our literature search, 11 studies (1 prospective series, 6 RCT and 4 retrospective studies) were finally identified. Based on our meta-analysis, there was statistically higher antibiotic concentration in the bone [mean difference (MD):25.12μg/g;95%CI:10.32,39.91;z=3.33,p=0.0009] and local fat tissues [MD:22.01μg/g;95%CI:1.71,32.30;z=4.19,p<0.0001) following IO prophylaxis, as compared with the systemic drug administration. IO prophylaxis was also associated with a significant reduction in prosthetic joint infections (PJI; April 1633 and 25/2213 patients developed PJI in IO and systemic prophylaxis groups, respectively; p=0.006). There was significant difference in gram-positive infections between IO and systemic prophylaxis groups (2/1123 and 13/1753g+ve infections in IO and systemic prophylaxis groups, respectively; p=0.05). Our review and meta-analysis revealed no substantial difference in complications amongst the groups (p=0.66). IO antibiotic prophylaxis appears to be an effective and safe strategy in patients undergoing TJA. IO access provides substantially enhanced antibiotic elution into the local tissues (bone and soft tissues); and consequently, results in reduced of PJI rates after TJA (in comparison with conventional systemic antibiotic prophylaxis).

Asymptomatic Elevated Inflammatory Markers: Is There a Risk for Infection or Revision in Primary Total Knee Arthroplasty?

Total knee arthroplasty (TKA) is the treatment of choice for advanced knee osteoarthritis. Long-term studies report high patient satisfaction, while complications such as periprosthetic joint infection (PJI) can be devastating. Knowledge regarding risk factors for PJI is critical to minimize and ideally avoid complications. The purpose of this study was to investigate the risk of PJI and revision in patients who had preoperative asymptomatic high C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels in primary TKAs. Patients undergoing primary TKA between 2010 and 2022 were eligible. Inclusion criteria were patients who had preoperative complete biochemical parameters and a minimum follow-up of 12 months. Patients who died during the first year, and those who had a history of inflammatory arthritis, autoimmune disease, renal pathologies, or septic arthritis, were excluded. Patients who had elevated blood CRP and ESR levels taken within 48hours before surgery underwent a thorough medical examination with a focus on infection symptoms. After screening and consultation, residual elevated CRP and ESR levels were classified as asymptomatic. After exclusions, 1,528 patients were included. The mean age was 66 years (range, 35 to 92), and the mean follow-up time was 6.4 years (range, 1.6 to 12.3). The rate of revision within one year after surgery was 1.6%, whereas the rate of revision in the first 5 years was 3.8%. The PJI rates for the 1st and 5th postoperative years were 1.7 and 2.9%, respectively. Regression analysis did not show any of the potential variables to be a risk factor for revision or PJI. Asymptomatic elevated acute-phase reactants are not a risk factor for periprosthetic joint infection or aseptic revision. At a mean follow-up of 6.4 years, overall survival was 96.7%, with only 2.2% of patients revised due to a PJI.

Radiographic Soft Tissue Thickness Is Not a Risk Factor for Infection after Primary Total Ankle Arthroplasty

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is a commonly performed surgical procedure to address end-stage arthritis. Previous studies have suggested that the radiographic soft tissue thickness may be a predictor of complications including periprosthetic joint infection (PJI) after orthopedic surgery. However, there has been limited studies exploring the use of radiographic soft tissue thickness in TAA. The purpose of this study was to evaluate the predictive capabilities of radiographic soft-tissue thickness for PJI following TAA. Methods: A retrospective analysis of 323 patients at a single institution who underwent primary TAA from 2003 to 2019 was conducted. Patient characteristics, including age, sex, body mass index (BMI), and comorbidities such as diabetes, smoking status, and etiology of ankle injury were recorded. Preoperative radiographic measurements, including the Tibial-Tissue and Talus-Tissue distances were recorded. Other perioperative information included prosthesis type, tourniquet time, and time to last follow-up. Logistic regression was utilized to examine the relationship between these factors and the occurrence of PJI. Results: Of the 323 patients, there were 6 patients (1.86%) who developed a PJI. The logistic regression analysis revealed that neither Tibial-Tissue (Odds Ratio: 0.975 [0.947 - 1.004]; p = 0.09) nor Talus-Tissue thickness (Odds Ratio: 0.976 [0.940 - 1.012]; p = 0.18) were significant predictors of PJI. Although not statistically significant, the infected cohort had smaller average Tibial-Tissue (2.20 vs. 2.53 cm; p=0.05) and Talus-Tissue thickness (2.19 vs. 2.44 cm; p=0.36) compared to the non-infected cohort. Conclusion: Despite an association between radiographic soft tissue thickness and infection in other orthopedic surgeries, measurements such as Tibial-Tissue length and Talus-Tissue length were not significant predictors of PJI following primary TAA. These findings underscore the necessity for additional research to identify modifiable risk factors aimed at reducing PJI rates and enhancing patient outcomes.

Nontobacco Nicotine Dependence and Rates of Periprosthetic Joint Infection and Other Postoperative Complications in Shoulder Arthroplasty: A Retrospective Analysis.

Nontobacco nicotine products, including e-cigarettes and vaping, are marketed as healthier alternatives to tobacco. However, the literature on nontobacco nicotine dependence (NTND) is scarce. It is important to analyze the influence of these products as they pertain to medical and surgical postoperative complications. This study hypothesizes that patients with NTND will experience more postoperative complications. Using the TriNetX database, which aggregates deidentified medical records from 89 healthcare organizations in the Research Network, Current Procedural Terminology and 10th revision of the International Classification of Diseases codes were used to identify patients undergoing primary shoulder arthroplasty (SA) from January 2012 to February 2024. Patients were divided into cohorts based on their NTND status before surgery. 90-day major medical complications and 2-year implant-related complications were assessed. Statistical analyses involved calculating risk ratios for postoperative complications. This study analyzed a total of 89,910 SA patients, of which 6,756 were 1:1 propensity matched into NTND or control cohorts. Within the 90-day postoperative period, the NTND cohort exhibited significantly higher rates of sepsis (1.80 vs. 1.20, P = 0.012), surgical site infection (1.20 vs. 0.70%, P = 0.007), and wound disruptions (0.70 vs. 0.40%, P = 0.048), average opioids prescribed (4.46 vs. 3.338, P < 0.001), readmission (10.20% vs. 6.20%, P 0.001) compared with the non-NTND cohort. At the 2-year follow-up, mechanical loosening was notably higher in the NTND group (1.10 vs. 0.30%, P 0.001), as were rates of prosthetic joint infections (2.20 vs. 1.20%, P 0.001). No significant difference was observed for revision rates (3.20% vs. 2.90%, P = 0.269). NTND is associated with higher 90-day rates of wound distruptions, infections, sepsis, as well as increased rates of mechanical loosening and prosthetic joint infection at 2 years postoperatively after SA. These results highlight the need for comprehensive NTND preoperative screening and tailored patient counseling in this patient population.

Low UKA implantation volume, comorbidities, male sex, and implantation of constrained TKA are risk factors for septic revision after knee arthroplasty implantation : A register-based study from the German Arthroplasty Register

Periprosthetic joint infection (PJI) is one of the main causes of revision surgeries after total knee arthroplasty (TKA) and unicondylar knee replacement. Patient- and hospital-related risk factors must be evaluated to prevent PJI. This study identifies influencing factors and differences in infection rates between various types of implant. The basis for the data is the German Arthroplasty Register (EPRD). Septic revisions were calculated with the aid of Kaplan-Meier estimates, with septic revision surgery defined as the primary endpoint. Patients with constrained and unconstrained TKA or UKA were analysed using the Holm multiple log-rank test and the Cox proportional hazard model. The 300,998 cases of knee arthroplasty analysed included 254,144 (84.4%) unconstrained TKA, 9993 (3.3%) constrained TKA and 36,861 (12.3%) UKA, with a maximum follow-up of 7 years. After 1 year, the PJI rate was 0.5% for UKA and 2.8% for TKA, whereas after 7 years it was 4.5% for UKA and 0.9% for TKA (p < 0.0001). In constrained TKA, the PJI rate was significantly increased compared with unconstrained TKA (p < 0.0001). After 1 year, the PJI rate was 2.0% for constrained TKA and 0.8% for unconstrained TKA, as well as 3.1% and 1.4% respectively after 7 years. Implantation of a constrained TKA (HR = 2.55), male sex (HR = 1.84), an increased Elixhauser Comorbidity Index score (HR = 1.18-1.56) and an implantation volume of less than 25 UKA per year (HR = 2.15) were identified as risk factors for revision surgeries; an Elixhauser Comorbidity Index score of0 (HR = 0.80) was identified as a preventive factor. A reduced implantation volume and constrained knee arthroplasty are linked to a higher risk of PJI. Comorbidities (increased Elixhauser Comorbidity Index score), male sex and a low UKA-implantation volume were identified as risk factors for PJI. Patients who fulfil these criteria need specific infection prevention measures. Further analyses are required to investigate the potential influence of prevention and risk factor modification. III.