Two-stage Revision Research Articles

Static vs Articulating Spacers for Two-Stage Revision Total Knee Arthroplasty: Minimum Five-Year Review.

BackgroundThe gold standard treatment for infected total knee arthroplasty (TKA) is two-stage revision. The first stage involves a temporary antibiotic spacer, which can be static or articulating; it remains unclear which is best. We aimed to compare 5-year outcomes between static and dynamic spacers.MethodsOne hundred and seventy-six patients with infected TKA requiring two-stage revision were enrolled. Patients were organized based on the type of spacer used during the first-stage revision. One hundred and four patients received articulating spacers, and 72 received static spacers. At 5 years, postoperative range of motion (ROM), Short Form 12 (SF-12), Knee Society Score (KSS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were recorded. Reinfection and revisions were also tracked.ResultsEradication of infection was similar in both groups, with 83.7% in the articulating group and 86.1% in the nonarticulating spacer group (P = .234). Articulating spacers resulted in significantly improved ROM (111 vs 82 degrees, P < .001), SF-12 physical component score (35.2 vs 31.0, P = .01), KSS (145.2 vs 113.7, P < .001), and WOMAC function scores (60.1 vs 51.1, P = .03) as compared to the static spacer group.ConclusionsTreatment with an articulating spacer as opposed to a static spacer resulted in improved ROM, SF-12 physical component score, KSS, and WOMAC function scores at the final follow-up visit. There was no significant difference in reinfection rates. Patients requiring staged revision for infected TKA may benefit from an articulating spacer.

Depression Is Transiently Increased in Patients Undergoing Two-Stage Revision Arthroplasty.

BackgroundThe implications of two-stage revision on mental health are poorly understood. The purpose of this study is to determine (1) whether patients undergoing two-stage revision total hip and knee arthroplasty for prosthetic joint infection were more likely to get Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores consistent with major depressive disorder (MDD) than those undergoing aseptic revision and (2) whether these symptoms resolved after the procedure.MethodsRecords of all 366 patients that underwent revision total hip or knee arthroplasty from January 1, 2015, – June 20, 2019, were reviewed. Forty-two patients were excluded for missing PROMIS Depression scores or incomplete treatment. Preoperative (<3 months), early postoperative (2-8 weeks), and final postoperative (6-18 months) Depression scores were collected. Patients crossing the PROMIS Depression threshold equivalent to a Patient Health Questionnaire-9 score ≥10, indicative of MDD, were evaluated.ResultsMore two-stage revision patients developed Depression scores indicative of MDD perioperatively than the aseptic cohort (20.0% vs 6.5%, P = .01). Two-stage revision patients had higher (worse) median Depression scores preoperatively (54.8 vs 51.3, P = .04) and at early follow-up (54.3 vs 49.9, P = .01), but not at final follow-up (50.4 vs 49.1, P = .39). Across all patients, Depression scores improved by 2.4 points at early follow-up (95% confidence interval:1.1–3.7; P < .001) and 3 points at final follow-up (95% confidence interval:1.5-4.5; P < .001; minimal clinically important difference 3.0).ConclusionsTwenty percent of two-stage revision arthroplasty patients, compared to <7% of aseptic revision patients, developed PROMIS Depression scores consistent with MDD during treatment. At final follow-up, a clinically significant improvement in Depression scores from baseline was evident in both cohorts.

Survival, functional outcome and satisfaction of first revision total knee arthroplasty at a mean eleven-year follow-up

PurposeProviding long-term outcome data after rTKA and compare one- versus two-stage and septic versus aseptic revisions.MethodsThis study represents a single-center retrospective study of first rTKAs performed for any reason with a final follow-up of a minimum of five years. Outcome parameters included stability assessment ROM, radiologic assessment, HSS score, KSS score, OKS score, EQ-5D-3L and VAS. 44 patients were included in the study. Subgroups analysis of one- versus two-stage revision and septic versus aseptic revision was performed.ResultsThe leading causes of rTKA in this mean 11 year follow-up study were aseptic loosening (36%) and periprosthetic joint infection (27%). At the final follow-up, there was a 89% survivorship of the implants. Patients showed a ROM of 114 ± 13°, HSS score of 78 ± 12, KKS objective score of 77 ± 16, KSS expectation and satisfaction score of 32 ± 11, KSS functional activity score of 50 ± 20, OKS of 30 ± 9, VAS of 53 ± 25 and EQ-5D index of 0.649. Functional outcome scores were not significantly altered in the analyzed subgroups.ConclusionsIn our 11 years follow-up, we obtained 89% implant survivorship. Measurements regarding functional outcome and pain showed results in the medium range of the respective scores, while patient satisfaction lay in the upper third. No significant differences in outcome scores between one- and two-stage revisions and septic versus aseptic revisions were observed.Level of Evidence Level III, retrospective cohort study.

Current Concepts on the Application, Pharmacokinetics and Complications of Antibiotic-Loaded Cement Spacers in the Treatment of Prosthetic Joint Infections.

Prosthetic joint infection (PJI) is a devastating complication of total joint replacement surgery. It affects about 2% of primary total joint replacements. Treatment aims at infection eradication and restoration of patient's mobility. Two-stage revision arthroplasty with an interim application of an antibiotic-loaded cement spacer (ALCS) is the widely accepted treatment for PJI. Spacers are powerful local carriers of antibiotics at the site of infection, effective against biofilm-protected microbes. On the other hand, spacers permit some mobility of the patient and facilitate final prosthesis implantation. ALCS's are either commercially available or prepared intraoperatively on prefabricated or improvised molds. Antibiotic elution from the spacer depends on the amount of the antibiotic used for cement impregnation, at the expense of mechanical stiffness of the spacer. The antibiotic should not exceed 4g per 40g of bone cement to preserve the mechanical properties of the cement. Spacers are frequently accompanied by local or systemic complications. The spacer may break, dislocate and compress vessels or nerves of the limb. Systemic complications are the result of excess elution of antibiotic and include nephrotoxicity, hepatotoxicity, ototoxicity, allergic reactions or neutropenia. Elderly patients with comorbidities are at risk to present such complications. Microbial resistance is a potential risk of long-lasting spacer retention. Persisting infection may require multiple spacer replacements.

Repeat two-stage exchange arthroplasty for recurrent periprosthetic hip or knee infection: what are the chances for success?

IntroductionTwo-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure.Materials and methodsWe retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22–51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan–Meier survival curves and comparative non-parametric testing.Results78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64–89%) after 1 year and 38% (95% CI 18–57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher’s exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients.ConclusionThe success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.

Двухэтапная ревизионная реконструкция передней крестообразной связки

With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. Two-stage revisions are rarely performed, but are particularly useful when addressing substantial tunnel-widening, active infection, and concomitant knee pathology (e.g., malalignment, other ligamentous injuries, meniscal or chondral lesions). Among these potential scenarios requiring a two-stage revision, tunnel-widening is the most common cause; the first stage involves graft removal, tunnel curettage, and bone grafting, followed by revision ACL reconstruction in the second stage. The purpose of this article is to review the preoperative planning, surgical considerations, rehabilitation, and outcomes of two-stage revision ACL reconstructions and summarize the recent literature outlining treatment results. Keywords: knee, anterior cruciate ligament, reconstruction, revision.

Contemporary outcomes of debridement, antibiotics and implant retention in knee arthroplasty.

Periprosthetic joint infection (PJI) is a major complication after knee arthroplasty, with approximately a quarter of knee arthroplasty revisions citing PJI as an indication. With the demand for knee arthroplasty predicted to increase, coupled with a lack of evidence for decreasing PJI risk, an appreciation of the burdens of PJI on both patients and health care systems is vital. Patients with PJI can experience a reduced quality of life as well as increased morbidity, whilst the management of PJI has significant economic implications. Surgical options include debridement, antibiotics and implant retention (DAIR), single-stage revision, two-stage revision and salvage procedures. DAIR involves the systematic debridement of all infected and unhealthy tissues coupled with directed antibiotic therapy, with definitive infection clearance the objective. In contrast to single- and two-stage revision procedures for PJI, DAIR does not involve the removal of fixed implants, with only modular components exchanged. Potential benefits of DAIR include reduced tissue destruction, reduced morbidity and reduced healthcare burdens, but with a higher reinfection risk compared to staged revision techniques, and utility largely restricted to acute bacterial PJI. A review of contemporary DAIR outcomes is of value given advances in the understanding of PJI biology; the development of consensus-based definitions for PJI diagnosis and treatment outcomes; and evolution of DAIR indications and technique. This review discusses outcomes of DAIR for knee PJI, published over the last two decades.

Staged revision still works for chronic and deep infection of total elbow arthroplasty?

Purpose: Infected total elbow arthroplasty (TEA) is challenging. We evaluate the clinical and radiologic outcomes for chronic and deep infection of TEA with two-stage revision surgery. Methods: A total of 10 elbows were included in the study. The mean age was 69.1 ± 15 years (range, 34–83 years). The mean follow-up was 62 (range, 24–108) months. The clinical outcomes were assessed using a visual analog scale (VAS), range of motion (ROM) arc, and Mayo elbow performance score (MEPS). Moreover, radiographic outcomes, time to revision, pathogenic bacteria, preoperative complications, and disease period were evaluated. Results: Mean preoperative VAS score of 6.1 had improved to 3.3. Mean preoperative ROM was 68° (flexion-extension), which improved to 86.7°. Mean preoperative MEPS was 46 (range, 0–70), which improved to 75.5 (range, 35–85). The mean disease duration was 8.4 months (range, 5–20 months). The most common causative organism was methicillin-resistant Staphylococcus aureus. The second revision rate was 80% at the final follow-up. Radiographic outcome at final follow-up showed that 3 (30%) of 10 patients exhibited radiolucency evidence around the components. Three patients showed nonprogressive radiolucency around the implant interfaces without other indications of infection at the most recent follow-up. Conclusion: In patients with chronic and deep infection of TEA, two-stage revision can be an affordable option for eradication of the infection, relieving pain, and restoring joint function. However, the high second revision rate owing to bone and soft-tissue deficits remains a critical issue.Level of evidence: Level IV, Case series, Treatment study

Truth or DAIR? A review of debridement, antibiotics and implant retention

Debridement, antibiotics and implant retention (DAIR) is a viable treatment option in early postoperative and acute haematogenous periprosthetic joint infections (PJIs) with a stable implant. Despite lower success rates compared to one- and two-stage revisions, DAIR maintains satisfactory outcomes in selected patient groups and, if successful, has similar functional outcomes to primary arthroplasty. DAIR remains an attractive treatment option, providing satisfactory outcomes with decreased healthcare costs, reduced surgical burden on the patient and shorter hospital stays. With success rates of 37-90%, various factors need to be considered when deciding on DAIR as the appropriate treatment option for PJI. The risk of DAIR failure needs to be weighed against the potential benefits of DAIR success. Factors that increase success rates include an open DAIR procedure performed for a low-virulence, antibiotic-sensitive organism, within a short duration between symptom onset and/or index surgery and DAIR. The procedure involves intraoperative exchange of mobile components and copious wound irrigation, followed by an appropriate antibiotic regimen for a minimum of six weeks that can be administered either intravenously or orally in a well-optimised host, without significant soft tissue defects or contraindications to surgery. Factors increasing the risk for DAIR failure include chronic/late PJIs with resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA) in poor hosts with significant comorbidities, such as chronic obstructive pulmonary disease (COPD), liver cirrhosis, rheumatoid arthritis, advanced age &gt; 80 years, patients with fracture indications for arthroplasty and those who cannot tolerate rifampicin- and fluoroquinolone-based antibiotic regimens. Unfortunately, there is no definitive factor to serve as an indication of whether DAIR will be successful, but with recent data showing that a failed DAIR procedure does not lower success in future staged revisions, then even in the face of a 50% success rate, DAIR can maintain its role as an initial treatment option in the management of PJIs

Two stage revision: indications, techniques and results.

Periprosthetic joint infection (PJI) is one of the most challenging complications a surgeon has to face after prosthetic replacement of a joint and one of the most devastating complications for the patient. During the 2018 International Consensus Meeting (ICM) in Philadelphia a numerical diagnostic tool was proposed. Contraindications to single stage revision include significant soft tissue injury with the inability to provide soft tissue cover, the presence of unknown or multi resistant organisms, lack of access to appropriate antibiotics or lack of appropriate expertise. Two stage revision surgery is indicated in these situations. Insall et al. described the surgical two-stage prosthetic revision technique in 1983: the in situ prosthesis is removed, a thorough debridement of bone and soft tissue is performed, an interval spacer is inserted, antibiotics administered. The 2nd stage of definitive reconstruction is performed once the infection is deemed to have resolved. The interval between stages can range from 6 weeks to several months. PJI are very challenging for every surgeon skilled in prosthetic surgery. It's necessary to make an exact preoperative diagnosis and to treat them with the proper technique. Further studies are needed to establish the perfect timing between the two stages, the duration of the antibiotic therapy and to standardize the diagnostic chart.

The Unusual Cause of Prosthetic Joint Infection: Outcomes of Nontuberculous Mycobacteria Treatment Following Primary Total Knee Arthroplasty.

Nontuberculous mycobacterium (NTM) is a rare cause of prosthetic joint infection (PJI) following primary total knee arthroplasty (TKA). NTM causes a variety of infections, mainly divided into pulmonary and extrapulmonary infections. In Pakistan, there was a 7.7-fold increase in NTM infections from 21 cases in 2012 to 163 cases in 2018. An earlier study evaluating the distribution of NTM species across Pakistan suggested geographical variation across different regions, every area having its own distribution spectrum. There are no data available especially in developing countries such as Pakistan regarding PJI due to NTM following primary TKA. The purpose of our study was to determine treatment outcomes of two-stage revision surgery following NTM infection. This is a retrospective study. Patients who underwent TKA between June 2008 and December 2018 were included in the study. NTM was defined as the presence of traditional criteria for diagnosing PJI plus growth of NTM cultured from a joint aspirate or deep periprosthetic tissue specimen using Löwenstein-Jensen medium and Mycobacteria Growth Indicator Tube medium. All patients were female with a mean age of 62.8 ± 7.9 years. The mean body mass index was 25.6 ± 2.8 kg/m2. Treatment outcomes were categorized into favorable and unfavorable. We found rapid-growing mycobacterium in 6 patients whereas slow-growing mycobacterium was found in 2 patients only. Generally, clarithromycin was the standard antibiotic used in all cases of NTM infections. All patients underwent revision surgery. Meticulous surgical debridement and prolonged antibiotic treatment course were the only hope of cure to combat the unusual cause of PJI following primary TKA.

Functional outcome of infected endoprosthesis: A 20-year retrospective analysis.

Bone tumours are increasingly treated with limb-salvage surgeries. However, implant infection is a devastating complication, greatly affecting the functional outcome. Yet, data on functional outcome post-implant infection are scarce. This study aims to determine the functional outcome and implant survival of these patients. Patients' data on endoprosthetic replacement surgeries at our institution (January 1996-December 2016) was retrospectively reviewed. Information was available for 161 patients and was analysed using SPSS and SMART Partial Least Squares. Functional outcome was determined using the Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage Score (TESS) scoring system. Both mean rank MSTS (33.14 vs 87.02) and TESS (48.17 vs 85.13) scores were significantly lower in the infected group. These differences remained statistically significant after excluding amputation and rotationplasty cases within the infected group. Even after the resolution of infection, both MSTS and TESS remained significantly higher in the non-infected group. However, analysis of the infected group showed no significant differences in functional outcome between persistent and resolved infections (implant in-situ). Age significantly impacted the functional outcome for both the non-infected and infected groups, while local recurrence and metastasis significantly impacted the non-infected cases. Local tumour recurrence was lower in infected endoprosthetic patients (8.3% vs 10.5%). 56% of infected implants were removed; the majority were treated with two-stage revision surgery. Endoprosthesis infection worsens the overall functional outcome. Additional factors affecting functional outcome were age, presence of local recurrence and metastatic disease. Local tumour recurrence was lower amongst infected endoprosthesis cases, and >50% of infected implants were removed.

Analysis of the cost of periprosthetic joint infections after total knee and hip arthroplasty and the effect of revision methods on the cost

Introduction. Periprosthetic joint infections (PJI) are known to increase medical costs, whereas the factors affecting this increase are variable. Aim. This retrospective case-control study aims to categorize and analyze the expenditures that increase costs in PJI and to evaluate the cost effect of revision methods. Material and methods. The patients who underwent primary arthroplasty or aseptic revision surgery of the knee or hip joints between January 2014-2018 in our center were screened retrospectively. Patients hospitalized with PJI were assigned as the PJI study group. The control group consisted at a 1:2 ratio and included patients matched for age, sex, prosthesis site, and the time from prosthesis implantation (years). All medical expenditures during the hospitalization period were determined and converted to United States dollar currency ($) according to annual average exchange rates. Results. Of the 4321 patients undergoing knee or hip arthroplasty in the mentioned timephrame, 87 patients had PJI, and 174 patients were enrolled as controls. The incidence of PJI was 2.1%. There was no difference between two groups in terms of demographic characteristics and comorbidities. The expenditures during hospitalization were $1,677 ($554.4-$13,605.2) per person in the PJI group and $494 ($269.3-$3,790.9) in the controls (p &lt; 0.001). The expense per person was 3.4 times higher in the PJI group than in the controls. The cost increase varied between 2-622 fold between the arms. When costs per procedure were evaluated, debridement, antibiotics, and implant retention was associated with lower costs while no difference was observed between one-or two-stage revisions ($1,188, $1,987, vs $1,854, respectively p &lt; 0.001). Conclusions. According to our study, antibiotics increase the cost more than surgical expenses in patients who develop PJI. In addition, cost should not be a factor in the decision of revision surgery.

Three Staged Revision Arthroplasty Using Structural Allograft in Chronic Periprosthetic Joint Infection Accompanied by Fracture: A Case Report

Revision arthroplasty for chronic periprosthetic joint infection is complex and determined by many variables. Generally, two-staged revision arthroplasty is the standard treatment for the management of chronic periprosthetic joint infection. However, it is difficult to resolve chronic infection accompanied by large bone deficiency due to pathologic fracture. I report a case of successful three-staged revision arthroplasty using frozen structural allograft in chronic periprosthetic knee joint infection accompanied by extensive bone defect due to fracture.

Repeat two‐stage revision for knee prosthetic joint infection results in very high failure rates

Two stage revision total knee arthroplasty (TKA) is the gold standard for treatment and eradication of knee prosthetic joint infections (PJI), but the literature is limited on the outcomes of repeat two-stage TKA after PJI recurrence. This study presents the outcomes of repeat two-stage revision TKA and investigates potential factors contributing to success or failure, aiming to assist counselling and decision-making. A retrospective study was undertaken investigating all two-stage revision TKA performed at one institution between 2005 and 2020. Twenty cases underwent repeat two-stage revision TKA. Patient outcomes and factors contributing to treatment success or failure were investigated. PJI was diagnosed according to MSIS criteria. Of the 20 cases, 14 were classified as failed treatment (70%) due to a failure to eradicate infection, further surgical intervention or death. In this cohort, there were no statistically significant differences between the groups regarding factors contributing to treatment success or failure. In the success group, patient reported functional outcomes were variable. This study demonstrates that patients undergoing a repeat two-stage TKA have very poor outcomes. This study did not identify any factors that predicted failure. Patients need to be counselled regarding poor outcomes with repeat two-stage TKA, and other treatment options such as early amputation or lifelong suppression should be considered.

Risk factors for infectious complications after total elbow arthroplasty

INTRODUCTION. Total elbow arthroplasty (TEA) is a good alternative surgical solution for many patients with severe traumatic and inflammatory joint injuries. However, this surgical procedure is characterized by a rather high incidence of periprosthetic joint infection (PJI): from 3 to 8 %. At present, the issue of the influence of various factors on the risk of PJI is relevant.The OBJECTIVE of the study was to identify risk factors for the development of PJI after primary TEA.METHODS AND MATERIALS. In a retrospective study, the data of 485 patients who underwent primary and revision TEA from 2003 to 2019 were analyzed. The total number of studied patients was divided into 2 groups. The main group consisted of 51 patients who underwent revision TEA for PJI. The control group included 434 patients who underwent primary TEA.RESULTS. Evaluation of the effect of the primary diagnosis on the risk of PJI development showed a statistically significant relationship only in patients with gunshot wounds of the elbow joint (p=0.01). In the study of possible anamnestic factors, the following were significant: a history of previous interventions on elbow joint (p=0.004), previous infection (p &lt;0.001) and open fracture of the elbow (p=0.009).CONCLUSION. In the course of the study, we proved the influence of anamnestic factors in the occurrence of PJI. Performing a two-stage revision allows stopping the infectious process with high efficiency in most cases.

Extended Trochanteric Osteotomy with Intermediate Resection Arthroplasty Is Safe for Use in Two-Stage Revision Total Hip Arthroplasty for Infection.

Background: This study sought to compare the results of two-stage revision total hip arthroplasty (THA) for periprosthetic infection (PJI) in patients with and without the use of an extended trochanteric osteotomy (ETO) for removal of a well-fixed femoral stem or cement. Methods: Thirty-two patients who had undergone an ETO as part of a two-stage revision without spacer placement were matched 1:2 with a cohort of sixty-four patients of the same sex and age who had stem removal without any osteotomy. Clinical outcomes including interim revision, reinfection and aseptic failure rates were evaluated. Modified Harris hip scores (mHHS) were calculated. Minimum follow-up was two years. Results: Patients undergoing ETO had a significantly lower rate of interim re-debridement compared to non-ETO patients (0% vs. 14.1%, p = 0.026). Reinfection following reimplantation was similar in both groups (12.5% in ETO patients vs. 9.4% in non-ETO patients, p = 0.365). Revision for aseptic reason was necessary in 12.5% in the ETO group and 14.1% in the non-ETO group (p = 0.833). Periprosthetic femoral fractures were seen in three patients (3.1%), of which all occurred in non-ETO patients. Dislocation was the most common complication, which was equally distributed in both groups (12.5%). The mean mHHS was 37.7 in the ETO group and 37.3 in the non-ETO group, and these scores improved significantly in both groups following reimplantation (p < 0.01). Conclusion: ETO without the use of spacer is a safe and effective method to manage patients with well-fixed femoral stems and for thorough cement removal in two-stage revision THA for PJI. While it might reduce the rate of repeated debridement in the interim period, the use of ETO appears to lead to similar reinfection rates following reimplantation.

Time Required for Planned and Unplanned Episodes of Care in Septic and Aseptic Hip and Knee Revision Surgery

Background: Surgical reimbursement rates are established by the Centers for Medicare and Medicaid Services (CMS). Studies have indicated that revision hip (rTHA) and knee (rTKA) arthroplasties require significantly more work effort, but are reimbursed less than primary procedures. This study quantified planned and unplanned work performed for revision surgeries by the surgeon and/or the surgeon’s team during the episode of care “reimbursement window.” Quantification of time was performed separately for aseptic and septic (two-stage) revisions and compared to allowed reimbursement amounts. &#x0D; &#x0D; Methods: All unilateral rTHA and rTKA procedures performed over a 10-year period by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. &#x0D; &#x0D; Results: Calculations demonstrated average per patient work for aseptic rTKA exceeded the reimbursable amount by 31 minutes. Calculated average minutes of work per patient required for aseptic rTHA fell within the number of minutes approved for reimbursement. Average per patient work for septic rTKA and rTHA exceeded the reimbursable amounts by 331 and 166 minutes, respectively, equating to 2.8 to 5.5 hours of uncompensated time. &#x0D; &#x0D; Conclusion: Revision hip and knee procedures are substantially more complex than primary procedures, with many surgeons referring patients to out-of-network care. Financially dis-incentivizing surgeons to care for these patients reduces patient access to care when high quality care is needed the most, especially infection cases susceptible to high sepsis and mortality rates. Study findings will be applied to advocacy efforts for appropriate legislative reform.

What is the appropriate extended duration of antibiotic prophylaxis after two-stage revision for chronic PJI?

AimsTo explore the effect of different durations of antibiotics after stage II reimplantation on the prognosis of two-stage revision for chronic periprosthetic joint infection (PJI).MethodsThis study involved a retrospective collection of patients who underwent two-stage revision for chronic PJI and continued to use extended antibiotic prophylaxis in two regional medical centres from January 2010 to June 2018. The patients were divided into a short (≤ one month) or a long (> one month) course of treatment based on the duration of antibiotics following stage II reimplantation. The difference in the infection control rate between the two groups was compared, and prognostic factors for recurrence were analyzed.ResultsA total of 105 patients with chronic PJI were enrolled: 64 patients in the short course group and 41 patients in the long course group. For 99 of the patients, the infection was under control during a follow-up period of at least 24 months after two-stage revision. For the short course group, the mean duration of antibiotic prophylaxis after stage II reimplantation was 20.17 days (SD 5.30) and the infection control rate was 95.3%; for the long course group these were 45.02 days (SD 15.03) and 92.7%, respectively. There was no significant difference in infection control rates between the two groups (p = 0.676). Cox regression analysis found that methicillin-resistant staphylococcus infection (p = 0.015) was an independent prognostic factor for recurrence.ConclusionAfter stage II reimplantation surgery of two-stage revision for chronic PJI, extended antibiotic prophylaxis for less than one month can achieve good infection control rate.Cite this article: Bone Joint Res 2021;10(12):790–796.

The outcome of the uncemented acetabular component in delayed total hip arthroplasty following acetabular fractures.

AimsAfter failed acetabular fractures, total hip arthroplasty (THA) is a challenging procedure and considered the gold standard treatment. The complexity of the procedure depends on the fracture pattern and the initial fracture management. This study’s primary aim was to evaluate patient-reported outcome measures (PROMs) for patients who underwent delayed uncemented acetabular THA after acetabular fractures. The secondary aims were to assess the radiological outcome and the incidence of the associated complications in those patients.MethodsA total of 40 patients underwent cementless acetabular THA following failed treatment of acetabular fractures. The postoperative clinical and radiological outcomes were evaluated for all the cohort.ResultsThe median (interquartile range (IQR)) Oxford Hip Score (OHS) improved significantly from 9.5 (7 to 11.5), (95% confidence interval (CI) (8 to 10.6)) to 40 (39 to 44), (95% CI (40 to 43)) postoperatively at the latest follow-up (p < 0.001). It was worth noting that the initial acetabular fracture type (simple vs complex), previous acetabular treatment (ORIF vs conservative), fracture union, and restoration of anatomical centre of rotation (COR) did not affect the final OHS. The reconstructed centre of rotation (COR) was restored in 29 (72.5%) patients. The mean abduction angle in whom acetabular fractures were managed conservatively was statistically significantly higher than the surgically treated patients 42.6° (SD 7.4) vs 38° (SD 5.6)) (p = 0.032). We did not have any case of acetabular or femoral loosening at the time of the last follow-up. We had two patients with successful two-stage revision for infection with overall eight-year survival rate was 95.2% (95% CI 86.6% to 100%) with revision for any reason at a median (IQR) duration of follow-up 50 months (16 to 87) months following THA.ConclusionDelayed cementless acetabular THA in patients with previous failed acetabular fracture treatments produces good clinical outcomes (PROMS) with excellent survivorship, despite the technically demanding nature of the procedure. The initial fracture treatment does not influence the outcome of delayed THA. In selected cases of acetabular fractures (either nondisplaced or with secondary congruency), the initial nonoperative treatment neither resulted in large acetabular defects nor required additional acetabular reconstruction at the time of THA.Cite this article: Bone Jt Open 2021;2(12):1067–1074.