Revision Of Infected Arthroplasty Research Articles

DIFFERENCES IN MORTALITY AND COMPLICATION RATES FOLLOWING REVISION KNEE ARTHROPLASTY PERFORMED FOR URGENT VERSUS ELECTIVE INDICATIONS

Revision knee arthroplasty is a complex procedure with the number and cost of knee revision procedures performed per year expected to rise. Few studies have examined adverse events following revision arthroplasty.The objective of this study was to determine rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications) and to compare these with primary arthroplasty and re-revision arthroplasty.Patients undergoing primary knee arthroplasty were identified in the UK Hospital Episode Statistics. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes including infection (undergoing surgery), pulmonary embolism, myocardial infarction, stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications were included in the elective indications cohort.939,021 primary knee arthroplasty cases were included of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% CI 0.37-0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44-0.47). Revision arthroplasty for infection, however, was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75-2.35; odds ratio [OR] 3.54; 95% CI 2.81-4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94-6.82; OR 6.23; 95% CI 4.39-8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort.These findings highlight the burden of complications associated with revision knee arthroplasty. They will inform shared decision-making for patients considering revision knee arthroplasty for elective indications. Patients presenting with infection of a knee arthroplasty or a periprosthetic fracture are at very high risk of adverse events. It is important that acute hospital services and tertiary referral centres caring for these patients are appropriately supported to ensure appropriate urgency and an anticipation for increased care requirements.

Estimating incidence rates of periprosthetic joint infection after hip and knee arthroplasty for osteoarthritis using linked registry and administrative health data.

The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA). This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC. The mean 90-day revision rate for infection was 0.1% (0.1% to 0.2%) for TKA and 0.3% (0.1% to 0.5%) for THA. The mean 90-day PJI rates defined by T84.5 were 1.3% (1.1% to 1.7%) for TKA and 1.1% (0.8% to 1.3%) for THA. The mean 90-day PJI rates using the extended definition were 1.9% (1.5% to 2.2%) and 1.5% (1.3% to 1.7%) following TKA and THA, respectively. When reporting the revision arthroplasty for infection, the AOANJRR substantially underestimates the rate of PJI at 90 days. Using combinations of infection codes and PJI-related surgical procedure codes in linked hospital administrative databases could be an alternative way to monitor PJI rates.Cite this article: Bone Joint J2022;104-B(9):1060-1066.

Cement Loaded With High-Dose Gentamicin and Clindamycin Reduces the Risk of Subsequent Infection After One-Stage Hip or Knee Arthroplasty Exchange for Periprosthetic Infection: A Preliminary Study.

The use of antibiotic-loaded acrylic cement for treating periprosthetic joint infections remains controversial. We hypothesized that the raw rate of surgical site infection (SSI) is lower after using cement loaded with high-dose gentamicin and clindamycin than after using cement loaded with standard-dose gentamicin for implant fixation during 1-stage hip and knee revision arthroplasty for infection. One hundred seventy-one continuous patients operated by 2 experienced surgeons during a 2-year period were included in the study. All patients were followed for 24 months. The primary endpoint was the raw rate of SSI after 2 years of follow-up time. The raw rate of SSI after 2 years of follow-up time was significantly lower in the study group (13%) than in the control group (26%) (P= .03) with an odds ratio of 0.42 (P= .03). These SSIs were new infections rather than a recurrence/persistence of the initial infection. The cement used in the study group significantly reduced the risk of SSI relative to the cement used in the control group. Routine use of this high-dose dual antibiotic-loaded cement can be considered during 1-stage knee or hip revision arthroplasty for infection.

Comparative meta-omics for identifying pathogens associated with prosthetic joint infection

Prosthetic joint infections (PJI) are economically and personally costly, and their incidence has been increasing in the United States. Herein, we compared 16S rRNA amplicon sequencing (16S), shotgun metagenomics (MG) and metatranscriptomics (MT) in identifying pathogens causing PJI. Samples were collected from 30 patients, including 10 patients undergoing revision arthroplasty for infection, 10 patients receiving revision for aseptic failure, and 10 patients undergoing primary total joint arthroplasty. Synovial fluid and peripheral blood samples from the patients were obtained at time of surgery. Analysis revealed distinct microbial communities between primary, aseptic, and infected samples using MG, MT, (PERMANOVA p = 0.001), and 16S sequencing (PERMANOVA p < 0.01). MG and MT had higher concordance with culture (83%) compared to 0% concordance of 16S results. Supervised learning methods revealed MT datasets most clearly differentiated infected, primary, and aseptic sample groups. MT data also revealed more antibiotic resistance genes, with improved concordance results compared to MG. These data suggest that a differential and underlying microbial ecology exists within uninfected and infected joints. This study represents the first application of RNA-based sequencing (MT). Further work on larger cohorts will provide opportunities to employ deep learning approaches to improve accuracy, predictive power, and clinical utility.

Differences in mortality and complication rates following revision knee arthroplasty performed for urgent versus elective indications.

To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort. A total of 939,021 primary knee arthroplasty procedures were included (939,021 patients), of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% confidence interval (CI) 0.37 to 0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44 to 0.47). Revision arthroplasty for infection was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75 to 2.35; odds ratio (OR) 3.54; 95% CI 2.81 to 4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94 to 6.82; OR 6.23; 95% CI 4.39 to 8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. These findings will be important for patient consent and shared decision-making and should inform service design for this patient cohort. Cite this article: Bone Joint J2021;103-B(10):1578-1585.

SINGLE STAGE KNEE ARTHROPLASTY REVISION SURGERY, OUR EXPERIENCE WITH ELEVEN CASES AND REVIEW OF THE LITERATURE

Knee replacement is a widely performed and very successful procedure for the management of knee arthritis. Nevertheless, it is postulated that a total of 2-5% of primary and revision total knee arthroplasties (TKAs) is infected every year [1,2]. Despite the low incidence, the absolute numbers of prosthetic joint infections (PJIs) are growing, owing to an increased number of replacement surgeries, and are associated with significant morbidity and socioeconomic burden [3,4]. Although several definitions of PJI exist, Musculoskeletal Infection’s Society (MSIS) definition is based on strict criteria and is one of the most used [5]. Patients with certain risk factors have an increased risk to develop PJI [6,7]. Risk factors include presence of systemic or local active infection in an arthritic knee; previous operative procedures in the same knee, diabetes mellitus, malnutrition, smoking, alcohol consumption, co-morbidities, and immunosuppression; end-stage renal disease on hemodialysis, liver disease, intravenous drug abuse, and low safety operative room environment. PJIs are classified according to the depth of infection, to superficial and deep infections. Superficial infections are limited to the incision and superficial tissues, while deep infections, that involve deep layers, may occur up to one year postoperatively, and influence surgical management strategy. Timing of infection is also an important factor in guiding treatment. PJIs are classified to acute postoperative, within a month of the index procedure, acute haematogenous, presenting with acute symptoms in a previously well – functioning joint, and late chronic, where infection develops later than one month postoperatively [8]. Management of PJI’s is mainly surgical, reserving conservative treatment for patients unable to undergo surgery [9]. Surgical options include debridement and retention of the prosthetic implants (DAIR), two – stage exchange revision, single – stage exchange revision, permanent resection arthroplasty, and finally amputation as the last measure [10]. DAIR is a viable option in early stages of acute infections, but established chronic infections necessitate more radical methods. Two – stage revision that was originally described by Install [11], secondly modified through the development of static spacers [12], and then articulating spacers [13], is considered the gold standard of TKA infection management [14]. A large volume of literature reports successful eradication of PJIs in more than 90% of patients using this approach [15,16,17]. Nevertheless, this procedure is costly, time-consuming, develops stiffness, arthrofibrosis, impairs mobility and increases inpatient stay. Single-stage revision arthroplasty for infection was first described in the 1980s [18, 19], has gained popularity for use in selected patients [20]. Infection control using this approach is achieved in 67% to 95% of patients [21, 22, 23, 24]. Furthermore, it is associated with less patient morbidity, improving functional outcome and reducing cost [25, 20]. This paper seeks to systematically review the results of using single – stage revision arthroplasty for chronic infection of TKAs. Furthermore, we report our experience with eleven cases of chronic knee arthroplasty infection, which were treated with the aforementioned technique.

Systematic review of single stage revision for prosthetic joint infection.

While advanced technology, increased medical knowledge and improved surgical technique has improved patient outcomes in total joint arthroplasty, prosthetic joint infection still remains one of the leading causes of increased healthcare costs, medical resources and societal burdens in orthopaedic care. Two stage arthroplasty revision remains the gold standard for treatment of prosthetic joint infection. Proponents of single stage revision arthroplasty for infection argue that it results in lower healthcare costs while improving patient reported functional outcomes and with equivalent success rates. Here we review the history of single stage revision arthroplasty, discuss the key principles, highlight the indications and contraindications, and review the reported outcomes with a focus on future developments of single stage revision arthroplasty for hip and knee periprosthetic joint infections.

Current actual success rate of the two-stage exchange arthroplasty strategy in chronic hip and knee periprosthetic joint infection

The success rates of two-stage revision arthroplasty for infection have evolved since their early description. The implementation of internationally accepted outcome criteria led to the readjustment of such rates. However, patients who do not undergo reimplantation are usually set aside from these calculations. The aim of this study was to investigate the outcomes of two-stage revision arthroplasty when considering those who do not undergo reimplantation, and to investigate the characteristics of this subgroup. A retrospective cohort study was conducted. Patients with chronic hip or knee periprosthetic joint infection (PJI) treated with two-stage revision between January 2010 and October 2018, with a minimum follow-up of one year, were included. Variables including demography, morbidity, microbiology, and outcome were collected. The primary endpoint was the eradication of infection. Patients who did not undergo reimplantation were analyzed in order to characterize this subgroup better. A total of 162 chronic PJIs were included in the study. After a mean follow-up of 57.3 months (12.1 to 115.7), 18 patients (11.1%) did not undergo reimplantation, due either to medical issues (10), the patient's choice (4), or death (4). When only considering those who underwent reimplantation, the success rate was 80.6%. However, when those who did not undergo reimplantation were included, the success rate dropped to 71.6%. Advanced age, American Society of Anesthesiologists grade ≥ III, McPherson's C host, and Gram-negative related PJI were independent risk factors for retention of the spacer. The mortality was higher in the non-reimplanted group. The real success rate of two-stage revision may not be as high as previously reported. The exclusion of patients who do not undergo reimplantation resulted in a 9% overestimation of the success rate in this series. Many comorbidity-related risk factors for retention of the spacer were identified, as well as higher death rates in this group. Efforts should be made to optimize these patients medically in order to increase reimplantation and success rates, while decreasing mortality. Cite this article: Bone Joint J 2020;102-B(12):1682-1688.

SAT-511 Refractory Hypercalcemia Secondary to Antibiotic Eluting Calcium Sulphate Beads

Hypercalcemia secondary to placement of antibiotic eluting calcium sulphate beads is rare. We present the case of a 58 year old Caucasian woman who presented with altered mental status, septic shock and respiratory failure. Labs showed hypercalcemia. History revealed placement of antibiotic-eluting calcium sulphate beads after removal of her infected left prosthetic hip joint two days before presentation. She had no known history of calcium, parathyroid disorders, fractures or kidney stones. Total serum calcium was elevated to 12.2 mg/dl (Ref 8.4-10.2 mg/dl) on admission with peak levels two days later at 15.7mg/dl. Her intact PTH was < 10.0 pg/ml (Ref 15-65.0 pg/ml); 1,25 Dihydroxy Vitamin D was 8.9 pg/ml (Ref 18-78.0 pg/ml) and 25 Hydroxy Vitamin D was 13 pg/ml (Ref 30-80 pg/ml) thus ruling out primary hyperparathyroidism, granulomatous disease or Vitamin D toxicity as etiology. Multiple myeloma work up was negative and was on no medications known to cause hypercalcemia. She received 8 doses of calcitonin (4 units/kg) but due to her worsening kidney function (< 30 ml/min), she could not receive a bisphosphonate. She became volume overloaded and required dialysis which corrected her hypercalcemia and renal function. She received 8 days of continuous renal replacement therapy followed by 2 sessions of hemodialysis which improved her serum calcium levels and renal function to normal range. Mental status also improved with improvement in her calcium levels. Duration of elevated calcium levels was 5 days. After dialysis was stopped, her calcium level and creatinine remained normal. In this case, hypercalcemia was attributed to antibiotic-eluting calcium sulphate beads. This case represents a rare etiology of hypercalcemia. On review of the literature, very few cases have been reported in humans. The first report to describe hypercalcemia following placement of calcium sulphate beads in humans was a case series consisting of 15 patients. Out of these patients, 3 developed hypercalcemia, one of which developed symptoms and required treatment with intravenous fluids and bisphosphonates.1 Another case reported a woman who suffered seizures due to a calcium leak into her cerebrospinal fluid after placement of calcium sulphate beads into her lumbar spine, however her serum calcium levels remained normal. 2 This case is one of a few reported in the literature of symptomatic hypercalcemia that occurred after placement of calcium sulphate beads. Further work is needed to understand those at risk of hypercalcemia from these agents. 1. Kallala R, Haddad FS. Hypercalcaemia following the use of antibiotic-eluting absorbable calcium sulphate beads in revision arthroplasty for infection. The bone & joint journal. 2015;97-b(9):1237-1241. 2. Smith I. Convulsions and Coma Associated with Iatrogenically Elevated CSF Calcium Levels Post Spinal Surgery: A Case Report. Crit Care Resusc. 2005;7(3):173-176.

Articulating antibiotic impregnated spacers in prosthetic joint infections: Where do we stand?

Peri-prosthetic joint infection remains one of the most difficult and challenging complications following hip and knee arthroplasty for both patients and surgeons. Two-stage revision arthroplasty for infection remains the most popular option for the majority of patients and arguably the only option for some. The use antibiotic spacers and in particular articulating spacers has improved the quality of life for patients between stages. The spacers provides local delivery of high concentration antibiotics and provides many benefits to the soft tissues including maintaining soft tissue tension and range of movement. This benefit to the soft tissues also translates into reducing the difficulty and time spent doing the exposure during the second stage procedure. It is generally accepted that peri-prosthetic joint infection should be dealt with my specialist centers who deal with high volumes of patients with this diagnosis in a multidisciplinary approach.

Single-Stage Revision Arthroplasty for Infection—An Underutilized Treatment Strategy

BackgroundThe burden of revision arthroplasty surgery for infection is rising as the rate of primary arthroplasty surgery increases. Infected arthroplasty rates are now relatively low, but the sheer increase in volume is leading to considerable patient morbidity and significant increases in costs to the health care system. Single-stage revision for infection is one of the several accepted treatment options, but the indications and results are debated. This review aims to clarify the current evidence. MethodsMEDLINE/PubMed databases were reviewed for studies that looked at single- or one-stage revision knee or hip arthroplasty for infection. ResultsThere is increasing evidence that single-stage revision for infection can control infection and with decreased morbidity, mortality, and health care costs compared with a staged approach. However, the indications are still debated. Recently, there has been a determined effort to define an infected arthroplasty in a manner that will allow for standardization of reporting in the literature. The evidence supporting single stage for knee arthroplasty is catching up with the result with hip arthroplasty. High-quality data from randomized controlled trials are now pending. ConclusionAfter the gradual evolution of using the single-stage approach, with the widespread acceptance of this definition, we can now standardize comparisons across the world and move toward a refined definition of the ideal patient population for single-stage arthroplasty revision in both the hip and the knee population.

Can a Silver-Coated Arthrodesis Implant Provide a Viable Alternative to Above Knee Amputation in the Unsalvageable, Infected Total Knee Arthroplasty?

BackgroundIn the unsalvageable, infected total knee arthroplasty, knee arthrodesis is one treatment option with lower reported reinfection rates compared with repeated 2-stage revision and improved function compared with amputation. One possible method for reducing incidence of recurrent infection treated by arthrodesis is the use of a silver-coated implant. We report our experience of silver-coated arthrodesis nails used for managing infected revision arthroplasty. We primarily assess the rate of reinfection and rate of amputation and report functional outcome measures. MethodsRetrospective analysis of all patients undergoing knee arthrodesis with a silver-coated arthrodesis nail between 2008 and 2014. Patient-reported data were recorded prearthrodesis and postarthrodesis (Oxford Knee Score and Short Form-36) as well as evidence of recurrent of infection, subsequent surgery, and the necessity for amputation. ResultsEight patients underwent arthrodesis using the silver-coated arthrodesis nail. Mean duration of follow-up was 16 months (5-35 months). At the point of follow-up, there were no amputations, deaths, or implant revisions. One case of recurrent infection was successfully treated with washout and debridement. The mean prearthrodesis and postarthrodesis Oxford Knee Score difference was +8.9 points (P = .086) with significantly improved pain (P = .019), night pain (P = .021), and ease of standing (P = .003). ConclusionArthrodesis of the knee using a silver-coated intramedullary device is successful in eradicating infection and allowing limb conservation. Where infection does recur, this can be successfully treated with implant retention. The use of a silver-coated arthrodesis nail should be considered as an alternative to amputation for patients with a multiply revised and infected total knee arthroplasty.

Hypercalcaemia following the use of antibiotic-eluting absorbable calcium sulphate beads in revision arthroplasty for infection.

Periprosthetic joint infection (PJI) is a devastating complication for patients and results in greatly increased costs of care for both healthcare providers and patients. More than 15 500 revision hip and knee procedures were recorded in England, Wales and Northern Ireland in 2013, with infection accounting for 13% of revision hip and 23% of revision knee procedures. We report our experience of using antibiotic eluting absorbable calcium sulphate beads in 15 patients (eight men and seven women with a mean age of 64.8 years; 41 to 83) as part of a treatment protocol for PJI in revision arthroplasty. The mean follow-up was 16 months (12 to 22). We report the outcomes and complications, highlighting the risk of hypercalcaemia which occurred in three patients. We recommend that serum levels of calcium be routinely sought following the implantation of absorbable calcium sulphate beads in orthopaedic surgery.

Antimicrobial activity of gentamicin and vancomycin combination in joint fluids after antibiotic-loaded cement spacer implantation in two-stage revision surgery

Gentamicin (G) and vancomycin (V) concentrations in joints fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision for infected arthroplasty, and the inhibitory activity of joint fluids against different multiresistant clinical isolates were studied. A total of 12 patients undergoing two-stage revision surgery with implantation of industrial G spacers added with different amounts of V was studied. Serum and joint fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and joint bactericidal titer (JBT) of combination were determined against multiresistant staphylococcal strains. The local release of G and V from PMMA cement seemed prompt and effective. Serum levels were below the limit of detection. The same joint fluid showed different activity according to the susceptibility of the pathogens tested. Gentamicin and V were released from spacers at bactericidal concentrations exerting a strong inhibition against methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS) strains.

A Systematic Review and Meta-Analysis of Antibiotic-Impregnated Bone Cement Use in Primary Total Hip or Knee Arthroplasty

BackgroundAntibiotic-impregnated bone cement (AIBC) has been widely used for the treatment of infected revision arthroplasty, but its routine use in primary total joint arthroplasty (TJA) remains considerably controversial. With this meta-analysis of published randomized controlled trials, we intended to assess the antimicrobial efficacy and safety of AIBC for its prophylactic use in primary TJA.MethodsA literature search was performed in MEDLINE, Embase, CBMdisc and the Cochrane Library until June, 2013. The studies were divided into two sub-groups according to the type of the control group. Outcomes of interest included postoperative infection rates, radiographic outcomes and clinical joint score. Study quality was evaluated using the Jadad scale (five points).ResultsIn total, eight studies were included, with a sample size of 6,381 arthroplasties. The overall pooled data demonstrated that, compared with the control (plain cement or systemic antibiotic), AIBC did not reveal an advantage in decreasing the rate of superficial infection (relative risk [RR] = 1.47; 95% CI, 1.13–1.91; P=0.004), while there were significant differences in deep infection rate between the AIBC and control group (RR = 0.41; 95% CI, 0.17–0.97; P=0.04). For the analysis of gentamicin and cefuroxime subgroups, the gentamicin was superior to the cefuroxime in reducing deep infection rate (P=0.0005 versus P= 0.10). However, no significant differences were found in their radiographic outcomes and clinical joint score.ConclusionThis meta-analysis had proven that the prophylactic use of AIBC could lower the deep infection rate in primary TJA, while AIBC did not show an improvement in reducing the superficial infection rate compared with the control. More sufficiently powered studies would be required to further evaluate the efficacy and safety of AIBC for primary TJA.

Argyria following the use of silver-coated megaprostheses

The aims of this study were to evaluate the incidence of local argyria in patients with silver-coated megaprostheses and to identify a possible association between argyria and elevated levels of silver both locally and in the blood. Between 2004 and 2011, 32 megaprostheses with silver coatings were implanted in 20 female and 12 male patients following revision arthroplasty for infection or resection of a malignant tumour, and the levels of silver locally in drains and seromas and in the blood were determined. The mean age of the patients was 46 years (10 to 81); one patient died in the immediate post-operative period and was excluded. Seven patients (23%) developed local argyria after a median of 25.7 months (interquartile range 2 to 44.5). Patients with and without local argyria had comparable levels of silver in the blood and aspiration fluids. The length of the implant did not influence the development of local argyria. Patients with clinical evidence of local argyria had no neurological symptoms and no evidence of renal or hepatic failure. Thus, we conclude that the short-term surveillance of blood silver levels in these patients is not required.

Minimizing Dynamic Knee Spacer Complications in Infected Revision Arthroplasty

Deep infections are devastating complications of TKA often treated with component explantation, intravenous antibiotics, and antibiotic-impregnated cement spacers. Historically, the spacers have been static, which may limit patients' ROM and ability to walk. Several recent reports describe dynamic spacers, which may allow for improved ROM and make later reimplantation easier. However, because of several dynamic spacer problems noted at our institution, we wanted to assess their associated failures, reinfection rates, and functionality. We therefore asked whether there were differences between static and dynamic spacers in (1) reinfection rates, (2) complications directly related to the spacer, and (3) final patient functionality as measured by Knee Society objective scores and ROM. We retrospectively identified 111 patients (115 knees) with 34 dynamic spacers (30%) and 81 static spacers (70%). Reinfection rates, complications requiring additional surgery, and final Knee Society scores and ROM were collected for all patients. Reinfection rates were comparable between groups. In the dynamic spacer cohort, there were four complications; however, these could all be explained by surgical technical errors or patient weightbearing compliance. All patients with failed results eventually underwent successful two-stage exchange arthroplasty. Final Knee Society scores and ROM were also similar between groups. Reinfection rates, Knee Society scores, and ROM were comparable between the static and dynamic spacer groups. Meticulous surgical technique and proper patient selection should be used to avoid any complications with any spacers.

Post-Operative Dressing of Total HIP and KNEE Replacements: Comparison of the Jubilee Dressing Method to a standard adhesive dressing

Post-Operative Dressing of Total HIP and KNEE Replacements: Comparison of the Jubilee Dressing Method to a standard adhesive dressing