Subsequent Periprosthetic Joint Infection Research Articles

The Safety and Efficacy of Microporous Polysaccharide Hemospheres in Terms of the Complication Rates in Total Hip Arthroplasty for Femoral Neck Fractures: A Control-Matched Retrospective Cohort.

This study aimed to assess the safety and efficacy of microporous polysaccharide hemospheres (MPSHs) in managing blood loss and reducing the risk of postoperative haematoma and early periprosthetic joint infection (PJI) following total hip arthroplasty (THA) for femoral neck fracture (FNF), in the context of the existing treatment challenges. A control-matched retrospective analysis of 163 patients undergoing unilateral primary THA for displaced FNF between 2020 and 2023 was performed. The study group consisted of 74 patients who received MPSH administered intraoperatively. The control group consisted of 89 patients who received no topical haemostatics. One-to-one case-control matching between groups was performed. The primary outcome was a perioperative change in the haematologic values (haemoglobin, red blood cell count, haematocrit, platelet concentration) and transfusion rate. The secondary outcomes were the incidence of postoperative local haematoma formation, prolonged wound secretion, surgical site infection (SSI), and PJI within 3 months of surgery. Our analysis found no statistically significant differences in the haematologic parameters between the control and study cohorts. The changes in the haemoglobin concentration were not significant between the control group (3.18 ± 1.0 g/dL) and the treatment group (2.87 ± 1.15 g/dL) (p = 0.3). There were no significant differences (p = 0.24) in the haematocrit and red blood cell concentration (p = 0.15). The platelet levels did not significantly differ (p = 0.12) between the groups. Additionally, we found no significant discrepancy in the incidence of early PJI or blood transfusion rates between the groups. No adverse effects following MPSH use were recorded in the study group. Routine use of MPSH in THA for FNF management appears to be safe, with no observed adverse events related to Arista® use. Although there was a tendency towards reduced blood loss in the Arista® AH group, MPSH did not significantly impact bleeding complications, local haematoma formation, or subsequent PJI.

Allograft or Synthetic Mesh Extensor Mechanism Reconstruction After TKA Carries a High Risk of Infection, Revision, and Extensor Lag.

Extensor mechanism disruption is a devastating complication after TKA. Extensor mechanism reconstruction can be performed using an allograft or synthetic mesh. Recent studies have disagreed about the durability of these reconstructions. Evaluating a larger series of reconstructions that use current popular techniques and principles provides information to guide patient and surgeon expectations while bringing to light the potential fate of patients who experience an infection postoperatively. (1) What was the 5-year survival free of repeat revision surgery or persistent extensor lag of more than 30° after allograft or synthetic mesh reconstruction of extensor mechanism disruptions after TKA, and did this differ between techniques? (2) What was the 5-year survival free of infection after allograft or mesh reconstruction, and what proportion of those patients experienced a secondary severe complication (arthrodesis or amputation)? Between April 2008 and December 2020, 123 patients underwent extensor mechanism reconstruction after TKA at one center. Of those, 37% (45) were lost to follow-up before 2 years, had not been seen in the past 5 years, did not reach a study endpoint (repeat revision or extensor lag > 30°) before that time, or underwent primary repair and thus could not be analyzed, leaving 63% (78) for analysis here. During the study period, we considered extensor mechanism surgery when acute or chronic disruption of the patellar or quadriceps tendon was present or there was a fracture of the patella resulting in extensor lag. The decision to use either mesh or an allograft largely depended on surgeon experience and familiarity with either technique. We collected patient demographics, operative details (location of disruption and presence of a hinged prosthesis), subsequent periprosthetic joint infection (PJI), and postoperative SF-12 and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores. We used Kaplan-Meier survivorship analysis, with endpoints of extensor lag more than 30° or revision of the reconstruction and PJI. The mean follow-up duration was 5.3 ± 3.2 years. Survivorship free from revision or recurrent extensor lag was 54% (95% CI 44% to 66%) at 5 years. There was no difference between those undergoing reconstruction with allografts and those with mesh in terms of survivorship free from those endpoints at that timepoint (52% [95% CI 40% to 68%] versus 57% [95 CI% 41 to 78%]; p = 0.99). Survivorship free from PJI was 81% (95% CI 73% to 90%) at 2 years. There was no difference between those with allografts and those with mesh in terms of survivorship free from PJI at that timepoint (79% [95% CI 69% to 92%] versus 83% [95% CI 71% to 98%]; p = 0.75). Of the 17 patients who experienced PJI, four ultimately underwent arthrodesis and three more underwent transfemoral amputation. Allograft and synthetic mesh reconstructions commonly left patients with persistent limb dysfunction, while several patients had PJI and some underwent salvage procedures. Although improvements have been made with regard to treating extensor mechanism disruptions, patients and surgeons should be well aware of the potential adverse outcomes when determining management and use these findings to conduct risk-benefit analyses. There is a need for future studies to identify protocols that improve the durability of reconstructions and to determine whether interventions such as prolonged prophylactic antibiotic therapy have a role in minimizing the risk of PJI. Level III, therapeutic study.

The Change of Serum Interleukin-6 Fails to Identify Subsequent Periprosthetic Joint Infection in Patients Who Have Two-Stage Revision for Periprosthetic Joint Infection

BackgroundThe diagnosis of persistent infection prior to second-stage reimplantation in 2-stage exchanges for periprosthetic joint infection (PJI) can be challenging as there is no optimal diagnostic tool. This study investigates the usefulness of pre-reimplantation serum C-reactive protein (CRP) and interleukin-6 (IL-6) and its change between both stages to identify patients who have subsequent PJI. MethodsThere were 125 patients who underwent planned 2-stage exchange for chronic knee or hip PJI from a single center retrospectively identified. Patients were included if preoperative CRP and IL-6 were available for both stages. Subsequent PJI was defined as 2 positive microbiological cultures at reimplantation or subsequent surgery or death due to PJI during follow-up. ResultsPrior to reimplantation, the median serum CRP (total knee arthroplasties [TKAs]: 1.0 versus 0.5 mg/dL, P = .028; total hip arthroplasties [THAs]: 1.3 versus 0.5 mg/dL, P = .015) and median IL-6 (TKA: 8.0 versus 6.0 pg/mL, P = .052; THA: 7.0 versus 6.0 pg/mL, P = .239) were higher in patients who had subsequent PJI. The IL-6 and CRP values showed moderate sensitivity (TKA/CRP: 66.7%; THA/CRP: 58.8%; TKA/IL-6: 46.7%; THA/IL-6: 35.3%) and good specificity (TKA/CRP: 66.7%; THA/CRP: 81.0%; TKA/IL-6: 86.3%; THA/IL-6: 83.3%). The change in CRP and IL-6 between the stages did not differ between the groups, respectively. ConclusionsSerum CRP and IL-6 show low to moderate sensitivity and good specificity in the diagnosis of subsequent PJI prior to reimplantation, which questions their usefulness as a rule-out test. Furthermore, the change in between stages does not appear to identify subsequent PJI.

Low Risk of Acute Iatrogenic Periprosthetic Joint Infection After Prosthetic Joint Aspiration

BackgroundSynovial fluid analysis is an essential tool in diagnosing periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, concern exists that aspiration may introduce infection into a noninfected joint. Therefore, the purpose of this study was to evaluate the incidence of iatrogenic PJI following diagnostic knee aspiration done within 6 months of the primary TKA. MethodsBetween 2017 and 2021, the senior surgeon performed over 4,000 primary TKAs and aspirated 155 knees in 137 patients for whom there was a suspicion for PJI within 6 months of their primary TKA. There were 22 knees diagnosed as infected from the initial aspiration and therefore were excluded from the study. The remaining 133 aspirates in 115 patients who were negative for infection were followed for 6 months for signs and symptoms of PJI to elucidate whether aspiration introduced infection into an initially noninfected joint. ResultsThere were 70 of 133 knees (52.6%) aspirated between 0 and 6 weeks after index TKA, 40 of 133 (30.1%) between 6 weeks and 3 months, and 23 of 133 (17.3%) between 3 and 6 months. At final follow-up, none of the 133 initially noninfected knees exhibited evidence of subsequent iatrogenic PJI or had subsequent surgery for infection. ConclusionWhile joint aspiration is a procedure with inherent risks, this study shows that the rate of iatrogenic PJI is extremely low (0%). Therefore, if infection is suspected, the surgeon should consider joint aspiration, even in the initial postoperative period, as the risk for introducing infection is far outweighed by the risk of missing an infection.

Single, Recurrent, Synchronous, and Metachronous Periprosthetic Joint Infections in Patients With Multiple Hip and Knee Arthroplasties

BackgroundThe rate for periprosthetic joint infection (PJI) exceeds 1% for primary arthroplasties. Over 30% of patients who have a primary arthroplasty require an additional arthroplasty, and the impact of PJI on this population is understudied. Our objective was to assess the prevalence of recurrent, synchronous, and metachronous PJI in patients who had multiple arthroplasties and to identify risk factors for a subsequent PJI. MethodsWe identified 337 patients who had multiple arthroplasties and at least 1 PJI that presented between 2003 and 2021. The mean follow-up after revision arthroplasty was 3 years (range, 0 to 17.2). Patients who had multiple infected prostheses were categorized as synchronous (ie, presenting at the same time as the initial infection) or metachronous (ie, presenting at a different time as the initial infection). The PJI diagnosis was made using the MusculoSkeletal Infection Society (MSIS) criteria. ResultsThere were 39 (12%) patients who experienced recurrent PJI in the same joint, while 31 (9%) patients developed PJI in another joint. Positive blood cultures were more likely in the second joint PJI (48%) compared to recurrent PJI (23%) or a single PJI (15%, P < .001). Synchronous PJI represented 42% of the second joint PJI cases (n = 13), while metachronous PJI represented 58% (n = 18). Tobacco users had 75% higher odds of metachronous PJI (odds ratio 1.75, 95% confidence interval: 1.1-2.9, P = .041). ConclusionOver 20% of the patients with multiple arthroplasties and a single PJI will develop a subsequent PJI in another arthroplasty with 12% recurring in the initial arthroplasty and nearly 10% ocurring in another arthroplasty. Particular caution should be taken in patients who use tobacco, have bacteremia, or have Staphylococcus aureus isolation at time of their initial PJI. Optimizing the management of this high-risk patient population is necessary to reduce the additional burden of subsequent PJI. Level of EvidencePrognostic Level IV.

What is the Safe Distance Between Hip and Knee Implants to Reduce the Risk of Ipsilateral Metachronous Periprosthetic Joint Infection?

Periprosthetic joint infection (PJI), the most common cause of revision after TKA and THA, is a devastating complication for patients that is difficult to diagnose and treat. An increase in the number of patients with multiple joint arthroplasties in the same extremity will result in an increased risk of ipsilateral PJI. However, there is no definition of risk factors, micro-organism patterns, and safe distance between knee and hip implants for this patient group. (1) In patients with hip and knee arthroplasties on the same side who experience a PJI of one implant, are there factors associated with the development of subsequent PJI of the other implant? (2) In this patient group, how often is the same organism responsible for both PJIs? (3) Is a shorter distance from an infected prosthetic joint to an ipsilateral prosthetic joint associated with greater odds of subsequent infection of the second joint? We designed a retrospective study of a longitudinally maintained institutional database that identified all one-stage and two-stage procedures performed for chronic PJI of the hip and knee at our tertiary referral arthroplasty center between January 2010 and December 2018 (n = 2352). Of these patients, 6.8% (161 of 2352) had an ipsilateral hip or knee implant in situ at the time of receiving surgical treatment for a PJI of the hip or knee. The following criteria led to the exclusion of 39% (63 of 161) of these patients: 4.3% (seven of 161) for incomplete documentation, 30% (48 of 161) for unavailability of full-leg radiographs, and 5% (eight of 161) for synchronous infection. With regard to the latter, per internal protocol, all artificial joints were aspirated before septic surgery, allowing us to differentiate between synchronous and metachronous infection. The remaining 98 patients were included in the final analysis. Twenty patients experienced ipsilateral metachronous PJI during the study period (Group 1) and 78 patients did not experience a same-side PJI (Group 2). We analyzed the microbiological characteristics of bacteria during the first PJI and ipsilateral metachronous PJI. Calibrated, full-length plain radiographs were evaluated. Receiver operating characteristic curves were analyzed to determine the optimal cutoff for the stem-to-stem and empty native bone distance. The mean time between the initial PJI and ipsilateral metachronous PJI was 8 ± 14 months. Patients were followed for a minimum of 24 months for any complications. The risk of ipsilateral metachronous PJI in the other joint secondary to a joint implant in which PJI develops can increase up to 20% in the first 2 years after the procedure. There was no difference between the two groups in age, sex, initial joint replacement (knee or hip), and BMI. However, patients in the ipsilateral metachronous PJI group were shorter and had a lower weight (1.6 ± 0.1 m and 76 ± 16 kg). An analysis of the microbiological characteristics of bacteria at the time of the initial PJI showed no differences in the proportions of difficult-to-treat, high virulence, and polymicrobial infections between the two groups (20% [20 of 98] versus 80% [78 of 98]). Our findings showed that the ipsilateral metachronous PJI group had a shorter stem-to-stem distance, shorter empty native bone distance, and a higher risk of cement restrictor failure (p < 0.01) than the 78 patients who did not experience ipsilateral metachronous PJI during the study period. An analysis of the receiver operating characteristic curve showed a cutoff of 7 cm for the empty native bone distance (p < 0.01), with a sensitivity of 72% and a specificity of 75%. The risk of ipsilateral metachronous PJI in patients with multiple joint arthroplasties is associated with shorter stature and stem-to-stem distance. Appropriate position of the cement restrictor and native bone distance are important in reducing the risk of ipsilateral metachronous PJI in these patients. Future studies might evaluate the risk of ipsilateral metachronous PJI owing to bone adjacency. Level III, therapeutic study.

981. Inducing Antimicrobial Resistance with Long-Term Antibiotics at Stage 2 Revision for Periprosthetic Joint Infection

Abstract Background Studies have shown reduced rates of recurrence of periprosthetic joint infection (PJI) with the use of oral antibiotics after stage-two revision. We examined the effects of these antibiotics on the antibiotic susceptibility patterns of subsequent PJI. Methods We conducted a retrospective cohort study of patients who underwent two-stage exchange for PJI in the Veterans Affairs system from 1/1/2015 – 6/1/2020. We compared patients who were prescribed oral antibiotic prophylaxis for ³14 days following stage-two revision arthroplasty with those who received &amp;lt; 14 days of antibiotics. The primary outcome was the presence of antibiotic-resistant organisms isolated in cultures from subsequent infections of the same joint. Secondary outcomes included comparisons of rates of recurrent PJI and time-to-subsequent PJI between each group. We used Chi square and Fisher exact tests to compare the two groups. Results 605 patients met inclusion criteria. Of these, 154 received ³14 days of oral antibiotics following stage 2 surgery. Tetracyclines (48.1%), beta-lactams (27.3%) and trimethoprim-sulfamethoxazole, TMP-SMX (18.8%) were the most common antibiotics used. There was decreased susceptibility to tetracyclines (58 vs 73%, p 0.24), TMP-SMX (48 vs 70%, p 0.059), and clindamycin (38 vs 57%, p 0.22) in organisms isolated from subsequent PJI in the antibiotic prophylaxis group compared to the control group. Subsequent PJI was diagnosed in 29 out of 154 (18.8%) in those who received antibiotic prophylaxis, compared with 80 of 451 (17.7%) who did not. Days to subsequent infection was higher for those who received antibiotics compared to those who did not (101 vs 65 days, respectively). Conclusion Prophylactic antibiotics following stage 2 revision for PJI may increase the risk for drug-resistant organisms in subsequent index joint infections, most notably against tetracyclines and TMP-SMX. Based on our data, antibiotics given after stage 2 revision postponed, rather than prevented, subsequent infection. Disclosures All Authors: No reported disclosures.

Extended Oral Antibiotics Increase Bacterial Resistance in Patients Who Fail 2-Stage Exchange for Periprosthetic Joint Infection

BackgroundAlthough studies have demonstrated reductions in recurrent periprosthetic joint infection (PJI) with the administration of prolonged oral antibiotics at second-stage reimplantation, the potential for increasing bacterial resistance has not been studied. The purpose of this study was to determine if oral antibiotics at second-stage reimplantation increased the rate of antibiotic resistance in subsequent infections. MethodsWe retrospectively reviewed patients who underwent 2-stage exchange for chronic PJI from 2014 to 2019. We compared those who had received prolonged oral antibiotics at the time of stage 2 reimplantation with those who did not. The primary outcome was the presence of resistant organisms in any subsequent infection. The secondary outcome was the overall rate of recurrent PJI in the 2 groups. Multivariable analyses controlling for demographics and comorbid conditions were used. ResultsOf the 211 patients who underwent 2-stage exchange for PJI, 158 patients received prolonged oral antibiotics. The mean follow-up was 2.2 years. Recurrent PJI was diagnosed in 24 of 158 (15%) patients who received oral antibiotics compared with 11 of 53 (21%) patients who did not receive antibiotics (P = .35). PJI with resistant organisms was identified in 16 of 24 (67%) patients who received antibiotics compared with 0 of 11 (0%) patients who did not receive antibiotics (P = .0001). ConclusionsProlonged oral antibiotics following 2-stage exchange increase drug resistance to that antibiotic in subsequent PJI. We recommend further research in the area to refine antimicrobial protocols as we consider the risks and benefits of prolonged antibiotic treatment.

Wound infection in elbow fractures: Incidence and new management protocol.

Wound infection in elbow fractures: Incidence and new management protocol.

Intra-Articular Corticosteroid Injection After Total Knee Replacement: Is it Safe?

Recalcitrant pain after total knee replacement (TKR) is sometimes treated with intra-articular steroid injections (IASI), with few studies reporting on the risk of subsequent periprosthetic joint infection (PJI). This is a systematic review to evaluate the incidence and risk of PJI after IASI into a total knee replacement.We searched online databases using the keywords "total knee replacement," "total knee arthroplasty," "steroids" and "intra-articular injection." A total of 7386 articles (PubMed - 91, Embase - 70, Web of Science - 57, CINAHL - 8, and Google Scholar - 7160) were retrieved on the initial search. After applying exclusion criteria, four articles were included in this review for evaluation and statistical analysis. There were no level one or two studies.The incidence of infection after IASI at 12 months was 138/6499 or 2.1%, while the incidence of infection rate among controls at 12 months was 158/11256 or 1.4%. A chi-square test showed that the difference in infection rate was significant (p = 0.0002424). A caveat is that simple statistical test results are virtually guaranteed to be statistically significant with large sample size.IASI into a TKR is not a benign procedure and that may be associated with a significantly increased risk of subsequent periprosthetic joint infection. We, therefore, recommend against IASI into a TKR until better studies can be performed to determine their safety and efficacy.

Superficial mycosis, at the site or distant to the surgical site, appears to predispose patients to bacterial periprosthetic joint infections.

It is traditionally believed that presence of fungal infection in the nail or skin of patients is a risk factor for subsequent infection. The literature is devoid of any evidence to confirm or refute this belief. This study examined a possible relationship between the presence of superficial skin or nail mycoses and subsequent periprosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA). This is a single-centre, retrospective study of patients who underwent primary TJA between 2000 and 2018. 55 patients with superficial mycoses of skin or nail, at the time of arthroplasty were identified and a variable number matching with up to a 1:5 ratio was performed with 182 patients undergoing TJA who had no superficial mycosis. The groups were further divided into knee and hip TJA. The outcome of TJA in the cohorts was compared. Preoperative demographics were similar between the 2 groups. The incidence of PJI in patients undergoing TKA within a year was significantly higher in patients with superficial mycosis at 8.6% (3/35) compared to 0% (0/120) in patients without mycosis. However, all infections were caused by bacterial species and none were fungal. Multiple regression analysis demonstrated that the presence of superficial mycosis had a strong correlation with development of PJI postoperatively in our TKA cohort. Identification of fungal infection (mycosis) of skin and nail in patients awaiting TJA is important. These patients appear to have a higher risk for developing bacterial PJI than those without fungal infections. Further study is needed to determine if treatment of these patients prior to arthroplasty stands to reverse the high risk for PJI that these patients carry.

Is there a problem with modular dual mobility acetabular components in revision total hip arthroplasty at mid-term follow-up?

Modular dual mobility (MDM) acetabular components are often used with the aim of reducing the risk of dislocation in revision total hip arthroplasty (THA). There is, however, little information in the literature about its use in this context. The aim of this study, therefore, was to evaluate the outcomes in a cohort of patients in whom MDM components were used at revision THA, with a mean follow-up of more than five years. Using the database of a single academic centre, 126 revision THAs in 117 patients using a single design of an MDM acetabular component were retrospectively reviewed. A total of 94 revision THAs in 88 patients with a mean follow-up of 5.5 years were included in the study. Survivorship was analyzed with the endpoints of dislocation, reoperation for dislocation, acetabular revision for aseptic loosening, and acetabular revision for any reason. The secondary endpoints were surgical complications and the radiological outcome. The overall rate of dislocation was 11%, with a six-year survival of 91%. Reoperation for dislocation was performed in seven patients (7%), with a six-year survival of 94%. The dislocations were early (at a mean of 33 days) in six patients, and late (at a mean of 4.3 years) in four patients. There were three intraprosthetic dissociations. An outer head diameter of ≥ 48 mm was associated with a lower risk of dislocation (p = 0.013). Lumbrosacral fusion was associated with increased dislocation (p = 0.004). Four revision THAs (4%) were further revised for aseptic acetabular loosening, and severe bone loss (Paprosky III) at the time of the initial revision was significantly associated with further revision for aseptic acetabular loosening (p = 0.008). Fourteen acetabular components (15%) were re-revised for infection, and a pre-revision diagnosis of reimplantation after periprosthetic joint infection (PJI) was associated with subsequent PJI (p < 0.001). Two THAs had visible metallic changes on the backside of the cobalt chromium liner. When using this MDM component in revision THA, at a mean follow-up of 5.5 years, there was a higher rate of dislocation (11%) than previously reported. The size of the outer bearing was related to the risk of dislocation. There was a low rate of aseptic acetabular loosening. Longer follow-up of this MDM component and evaluation of other designs are warranted. Cite this article: Bone Joint J2021;103-B(7 Supple B):66-72.

Direct Anterior Approach to the Hip Does Not Increase the Risk for Subsequent Periprosthetic Joint Infection

BackgroundRecent studies suggest an increased risk for periprosthetic joint infection (PJI) utilizing the direct anterior (DA) approach to the hip. The purpose of this study was to investigate whether such an increased risk does indeed exist on a large cohort of patients, operated by experienced surgeons and taking into account various confounders. MethodsThis was a single institutional study, including all patients who underwent primary total hip arthroplasty during the last decade, who were operated on by four high-volume arthroplasty surgeons utilizing a single surgical approach. Three of them utilized the direct lateral (DL) approach while one of them used the DA approach throughout the entire study. Patient characteristics, demographics, and comorbidities were assessed as well as operative and perioperative factors and their association with PJI. Association between surgical approach and PJI was evaluated in a univariate followed by a multivariate regression analysis. ResultsA total of 10,201 patients were included in the study. Of those, 4390 (43.0%) underwent total hip arthroplasty through the DA approach and 5811 (57.0%) through the DL approach. PJI rates were 0.9% (38/4390) in the DA group compared with 1.3% (73/5811) in the DL group (P = .068). Results from a regression analysis showed no significant association between PJI and DA approach (adjusted odds ratio 0.760, 95% confidence interval 0.428-1.348, P = .348). The risk remained nonsignificant in patients with higher body mass index. There were also no significant differences in the infecting organisms between the two groups. ConclusionThe DA approach to the hip does not increase the risk for subsequent PJI.

When Total Joint Arthroplasty After Septic Arthritis Can Be Safely Performed.

Background:Patients undergoing total joint arthroplasty (TJA) following septic arthritis are at higher risk for developing periprosthetic joint infection (PJI). Minimal literature is available to guide surgeons on the optimal timing of TJA after completing treatment for prior native joint septic arthritis. This multicenter study aimed to determine the optimal timing of TJA after prior septic arthritis and to examine the role of preoperative serology in predicting patients at risk for developing PJI.Methods:A total of 207 TJAs were performed after prior septic arthritis from 2000 to 2017 at 5 institutions. Laboratory values, prior treatment, time from the initial infection, and other variables were recorded. Bivariate analyses were performed to identify the association between the time from septic arthritis to TJA and the risk of developing subsequent PJI. A subanalysis was performed between patients who underwent TJA in 1 setting (n = 97) compared with those who underwent 2-stage arthroplasties (n = 110). Receiver operating characteristic (ROC) curve analysis was performed for serum markers prior to TJA in predicting the risk of a subsequent PJI.Results:The overall PJI rate was 12.1%. Increasing time from septic arthritis treatment to TJA was not associated with a reduction of PJI, whether considering time as a continuous or categorical variable, for both surgical treatment cohorts (all p > 0.05). Although the ROC curve analysis found that the optimal threshold for timing of TJA from the initial treatment was 5.9 months, there was no difference in the PJI rate when the overall cohort was dichotomized by this threshold and when stratified by 1-stage compared with 2-stage TJA. There was no significant difference in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level prior to conversion TJA between patients who subsequently developed PJI and those who did not.Conclusions:Serum markers have limited value in predicting subsequent PJI in patients who undergo TJA after prior septic arthritis. There was no optimal interim period between septic arthritis treatment and subsequent TJA; thus, delaying a surgical procedure does not appear to reduce the risk of PJI.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Fate of Periprosthetic Joint Infection Following Megaprosthesis Reconstruction.

Background:A megaprosthesis may be used for reconstruction in patients with massive bone loss or a periprosthetic fracture. Periprosthetic joint infection (PJI) may occur after a megaprosthesis reconstruction and may pose a major challenge. The outcomes of managing PJI in patients with a megaprosthesis is relatively unclear. The aim of this study was to investigate the clinical course and outcomes of PJI in patients with a megaprosthesis in place.Methods:From a total of 219 patients who underwent megaprosthesis replacement for non-oncologic conditions, 38 (17.4%) developed subsequent PJI. A retrospective review of the medical record was performed to ascertain the course of the PJI and treatment outcomes. Kaplan-Meier analysis was performed to evaluate the survival function, and the log-rank test was used to assess differences in outcome measures.Results:The surgical management of 33 patients with PJI included debridement, antibiotics, and implant retention (DAIR) (82%), consisting of DAIR with modular component exchange (19 patients) and DAIR without component exchange (8 patients); 2-stage exchange arthroplasty (9%); resection arthroplasty (6%); and a single-stage revision arthroplasty (3%). The Kaplan-Meier survivorship analysis demonstrated that the overall survival rate was 65.1% at 2 years. The mortality rate was 15%, with many patients undergoing salvage procedures including amputation (18%), arthrodesis (6%), and resection arthroplasty (6%).Conclusions:The rate of PJI after megaprosthesis reconstruction, 17% in this study, appears to be very high. The management of PJI in these patients is challenging, with 1 of 3 patients undergoing failed treatment. Despite the limited options available, DAIR seems to be an appropriate treatment strategy for some of these patients. Further data on a larger cohort are needed to assess the success of various surgical procedures and predictors of failure in this challenging patient population.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High Rate of Reinfection With New Bacteria Following One-Stage Exchange for Enterococcal Periprosthetic Infection of the Knee: A Single-Center Study

BackgroundA wide range of success rates following the surgical management of enterococcal periprosthetic joint infection (PJI) with a tendency toward worse outcomes have been reported. However, the role of 1-stage exchange remains under-investigated. Therefore, we aimed to evaluate our results after the 1-stage knee exchange for enterococcal PJI. MethodsForty patients were retrospectively included between 2002 and 2017 with a mean follow-up of survivors of 80 months (range 22-172; standard deviation [SD] = 5). Polymicrobial infections occurred in 45% (18/40) of patients. Patients’ characteristics, joint-related data, and antibiotic therapy were recorded. Rates of enterococcal infection relapse, reinfection with new microorganisms, and re-revision for any reason were determined. Bivariate analysis was conducted to identify risk factors of infection recurrence. ResultsRevision surgery was required in 22 cases (55%) with a mean time to revision surgery of 27 months (range 1-78; SD = 25). Indications for aseptic revisions (18%) included aseptic loosening (10%), periprosthetic fracture (5%), and patellar instability (3%). The most common cause of re-revision was a subsequent PJI (15/22; 68%) after a mean time of 22 months (range 1-77; SD = 24). Overall infection recurrence rate was 37.5% (15/40), substantially due to entirely non-enterococcal infections (9/15; 60%). Infection relapse with Enterococci occurred in 4 cases (10%) within 16 months postoperatively. Older patients (P = .05) and male gender (P = .05) were associated with a higher risk of infection recurrence. ConclusionOvercoming the Enterococci using the 1-stage exchange for knee PJI is achievable but the rate of reinfection due to new microorganisms is high . However, the overall infection recurrence rate is comparable to other treatment approaches.

Risk of Prosthetic Joint Infection Increases Following Early Aseptic Revision Surgery of Total Hip and Knee Arthroplasty

BackgroundIt is important to identify risk factors for periprosthetic joint infection (PJI) following total joint arthroplasty in order to mitigate the substantial social and economic burden. The objective of this study is to evaluate early aseptic revision surgery as a potential risk factor for PJI following total hip (THA) and total knee arthroplasty (TKA). MethodsPatients who underwent primary THA or TKA with early aseptic revision were identified in 2 national insurance databases. Control groups of patients who did not undergo revision were identified and matched 10:1 to study patients. Rates of PJI at 1 and 2 years postoperatively following revision surgery were calculated and compared to controls using a logistic regression analysis. ResultsIn total, 328 Medicare and 222 Humana patients undergoing aseptic revision THA within 1 year of index THA were found to have significantly increased risk of PJI at 1 year (5.49% vs 0.91%, odds ratio [OR] 5.61, P < .001 for Medicare; 7.21% vs 0.68%, OR 11.34, P < .001 for Humana) and 2 years (5.79% vs 1.10%, OR 4.79, P < .001 for Medicare; 8.11% vs 1.04%, OR 9.05, P < .001 for Humana). Similarly for TKA, 190 Medicare and 226 Humana patients who underwent aseptic revision TKA within 1 year were found to have significantly higher rates of PJI at 1 year (6.48% vs 1.16%, OR 7.69, P < .001 for Medicare; 6.19% vs 1.28%, OR 4.89, P < .001 for Humana) and 2 years (8.42% vs 1.58%, OR 6.57, P < .001 for Medicare; 7.08% vs 1.50%, OR 4.50, P < .001 for Humana). ConclusionEarly aseptic revision surgery following THA and TKA is associated with significantly increased risks of subsequent PJI within 2 years.

Aseptic Reoperations Within 1 Year of Primary Total Knee Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection

BackgroundDespite the high rate of success of primary total knee arthroplasty (TKA), some patients are candidates for early aseptic reoperation. The goal of this study is to evaluate the risk of subsequent periprosthetic joint infection (PJI) in patients treated with an aseptic reoperation within 1 year of primary TKA. MethodsA retrospective review of our total joint registry compared 249 primary TKAs requiring an aseptic reoperation within 1 year following index arthroplasty to a control group of 17,867 TKAs not requiring reoperation within 1 year. Patients were divided into groups based on time from index TKA: (1) 90 days or less (114 TKAs) and (2) 91 to 365 days (135 TKAs). Mean age was 68 years with 57% female. Mean follow-up was 7 years. ResultsAt 2 years postoperatively, patients undergoing an aseptic reoperation within 90 days subsequently had a 9% PJI rate, while patients undergoing an aseptic reoperation between 91 and 365 days subsequently had a 3% PJI rate. The control group had a 0.4% PJI rate. Compared to the control group, patients undergoing an aseptic reoperation within 90 days had an elevated risk of PJI (hazard ratio, 9; P < .0001), as did patients who had a reoperation between 91 and 365 days (hazard ratio, 4; P < .0001). ConclusionAseptic reoperation within 1 year of primary TKA was associated with a notably increased risk of subsequent PJI.

Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty.

Revision total joint arthroplasty (TJA) has a higher rate of periprosthetic joint infection (PJI) compared with primary TJA, possibly as the result of increased allogeneic blood transfusion. Tranexamic acid (TXA) is gaining popularity in revision TJA to minimize blood loss and the need for transfusion; however, its effect on PJI reduction has yet to be investigated. The hypothesis of this study was that the administration of TXA during revision arthroplasty is protective against subsequent PJI. A prospectively maintained institutional database was used to identify patients who underwent revision TJA for aseptic failure from 2009 to 2018 and had a minimum follow-up of 90 days. Patients who developed PJI following revision arthroplasty were identified. All patients with PJI met Musculoskeletal Infection Society (MSIS) criteria. A multivariate analysis was performed to identify variables independently associated with PJI after aseptic revision TJA. Overall, 1,731 patients who underwent aseptic revision were identified; of these patients, 83 (4.8%) developed PJI. Patients who received TXA had significantly lower rates (p = 0.029) of PJI postoperatively at 3.30% compared with those who did not receive TXA at 5.73%. After controlling for relevant confounding variables, TXA remained a significant independent factor that protected against PJI (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.23 to 0.90]; p = 0.030). Female sex was also identified as a significant independent factor that protected against PJI (OR, 0.52 [95% CI, 0.30 to 0.88]; p = 0.016). However, preoperative anemia was independently associated with an increased risk of subsequent PJI (OR, 2.37 [95% CI, 1.34 to 4.16]; p = 0.003). Based on this study conducted at a single institution, the use of TXA during aseptic revision arthroplasty was independently associated with a reduced risk of subsequent acute PJI after adjusting for multiple patient characteristics and surgical factors. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Periprosthetic Joint Infection in Patients Who Have Multiple Prostheses in Place: What Should Be Done with the Silent Prosthetic Joints.

Although periprosthetic joint infection (PJI) can affect multiple joints concurrently, the majority of patients with multiple prosthetic joints present with PJI of a single joint. Data regarding the optimal management of these patients are limited. We aimed to identify the prevalence, risk factors for a subsequent PJI, and clinical circumstances of PJI in patients with multiple prosthetic joints. We retrospectively reviewed the clinical records of 197 patients with ≥2 total joint prostheses in place who presented with PJI from 2000 to 2017. The average follow-up was 3.6 years (range, 0.5 to 17 years). Demographic data and risk factors for synchronous or metachronous PJI were identified. The time from the initial to the second PJI and organism profile data were collected as well. The workup for other joints with a prosthesis in place at the time of the initial PJI was noted. Among the 197 patients with PJI and multiple joint prostheses in situ, 37 (19%) developed PJI in another joint; 11 had a synchronous PJI and 26 had a metachronous PJI. The average time between the first and the second infection in the metachronous cases was 848 days (range, 20 to 3,656 days). Females and patients with an initial PJI with methicillin-resistant Staphylococcus aureus (MRSA) were more likely to have a metachronous PJI, and patients with rheumatoid arthritis had an increased risk of a second (metachronous or synchronous) PJI. Three of 11 patients in the synchronous group and 19% (5) of the 26 in the metachronous group had bacteremia at the time of the initial PJI compared with 12% (19) of the 160 with a single PJI. The percentage of negative cultures increased from 10% for the initial PJIs to 38% for the metachronous PJIs. Patients who have multiple prosthetic joints in place and present with PJI of a single joint are at risk of developing PJI in another joint. Female sex, rheumatoid arthritis, bacteremia at presentation, and infection with MRSA appear to be risk factors for PJI of another joint. Clinical evaluation of the other prosthetic joint(s) should be carried out in all patients and aspiration of those joint(s) should be considered for patients with any of the above risk factors. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.