Clinical outcomes and survivorship of two-stage total hip or knee arthroplasty in septic arthritis: a retrospective analysis with a minimum five-year follow-up

Excellent Survival Rate of Cemented Modular Stems in One-Stage Revision for Periprosthetic Hip Infections With Massive Femoral Bone Loss: A Retrospective Single-Center Analysis of 150 Cases

BACKGROUND

With the increasing incidence of total hip arthroplasty (THA), there is also an expected concurrent increase in revision THA (rTHA), which is known to have a high complication and re-revision rate. In the setting of infection, radical debridement is essential and options for femoral bone loss are limited. One viable solution is cemented modular stems, but limited evidence exists on their use in septic revision. This study aimed to analyze survival and complication related to the use of cemented modular stems in one-stage septic rTHA with severe femoral bone loss.

METHODS

The institutional database of patients who underwent rTHA for septic one-stage revision with cemented modular stems was reviewed. Exclusion criteria were patients aged less than 18 years and nonseptic or 2 stage revisions. Outcomes measured were complication, re-infection, re-operation, and survivorship of the implant. A total of 150 patients were included. The mean age was 68 years (range, 30 to 91), and the mean follow-up was 105 months (range, 1 to 150).

RESULTS

Treatment was considered successful in 81.3% of cases. Patients who underwent multiple prior surgeries demonstrated a lower rate of treatment success (P < .001). The main cause of failure was re-infection (11 of 28). Among cases failed for aseptic reasons (17 of 28), loosening of the cemented modular stem was the cause of re-revision in 2 patients (1.3%).

CONCLUSIONS

The use of modular cemented stems is a viable option in case of septic one-stage rTHA associated with severe femoral bone loss. However, surgeons and patients should be aware that this treatment is still characterized by a high rate of complications, which may lead to further surgeries.

LEVEL OF EVIDENCE

III.

The Use of Barbed Sutures in Total Hip Arthroplasty: A Systematic Review on Clinical-Surgical Outcomes, Costs, and Complications

PURPOSE

Total hip arthroplasty is among the most successful procedures in orthopaedic surgery. As the total number of total hip arthroplasties is constantly rising and it is expected to further increase, efforts oriented to optimise surgical pathways are investigated, aiming to reduce complications and diminish costs. The wound suturing phase is one of the steps that may be addressed. Barbed sutures have proved to reduce surgical times and enhance suture stability, then reducing wound-related complications in many surgical fields. The evidence on the use of this technology in total hip arthroplasty is still sparse, and its effect on patient outcomes and costs must still be clarified.

METHODS

A systematic search of studies published from 1 January 2000 to 1 March 2023 was performed. Two authors independently reviewed the literature available in eight electronic databases to identify papers eligible for inclusion.

RESULTS

A total of nine studies investigating 6959 procedures on 6959 patients were included in the final analysis. Five studies were randomised controlled trials, and the overall quality of studies ranged from moderate to high. The mean age of patients ranged from 43.8 to 70 years. BMI ranged from 25 to 31.9 kg/m2. The mean follow-up of studies ranged from 3 to 6 months.

CONCLUSIONS

Evidence included in the systematic review suggested that the use of barbed sutures is associated with lower suturing times, complication rates, and overall costs when compared to the use of traditional suturing techniques.

LEVEL OF EVIDENCE

II, systematic review of level I and II studies.

Use of 1.5-Stage Functional Articulating Hip Spacers for Two-Stage Treatment of Hip Infection

BACKGROUND

A two-stage treatment is commonly used for chronic hip infections. This study compared the clinical efficacy and complications associated with 1.5-stage functional articulating hip spacers (FAHS) and handmade spacers utilized during two-stage treatment.

METHODS

This retrospective study included 50 patients who had hip infections, of which 41 were periprosthetic joint infections, 3 were internal fixation infections, and 6 had septic arthritis. They were divided into two groups according to the spacer type: 23 patients treated with handmade spacers comprising 1 to 2 Kirschner wires as an endoskeleton (group A) and 27 patients treated with 1.5-stage FAHS comprising a cemented femoral stem, metal femoral head, and polyethylene acetabular liner or cemented acetabular cup (group B). Clinical characteristics, surgical data, infection control rate, spacer complications, modified Harris hip, visual analog scale, and 36-item short-form physical functioning scale scores were compared between the groups. All patients were followed up for at least 24 months after the last surgical procedure.

RESULTS

No significant differences were noted in the infection eradication rate between the two groups (100 versus 96.30%, P = 1.0). The incidence of mechanical complications, especially spacer fracture, was significantly lower in group B than in group A (P = .044). Hip function and quality of life were significantly better in group B during the interim period. Group B patients had a longer interval time (median 7.40 versus 4.30 months, P = .004) and a lower reimplantation rate than group A patients (42.31 versus 82.61%, P = .004).

CONCLUSIONS

The 1.5-stage FAHS surgical technique is feasible for the treatment of hip infection, with a lower mechanical complication rate, better hip function, and better quality of life during the interim period compared to that of handmade spacers. The 1.5-stage FAHS with maintained function could delay or negate the need for second-stage revision.

Two-stage total joint replacement for hip or knee septic arthritis: post-traumatic etiology and difficult-to-treat infections predict poor outcomes

PURPOSE

Septic arthritis (SA) is a rare but significant clinical challenge in orthopedics that can impact patients' quality of life. This study aims to examine the clinical outcomes of patients undergoing two-stage total joint replacement (TJR) in hip and knee SA and analyze potential predictors of treatment failure.

METHODS

A retrospective analysis was conducted using data from a prospectively collected institutional arthroplasty registry from January 1st, 2012, to January 1st, 2019. Patients with hip or knee SA who underwent a two-stage TJR and had at least two years of follow-up were included. Demographic characteristics, surgical variables, and outcomes were collected and analyzed from clinical and surgical data. Statistical analysis was performed using IBM SPSS Statistics, with statistical significance at p < 0.05.

RESULTS

One hundred and fourteen patients (61 with hip SA, 53 with knee SA) were included in the study. The mean follow-up was 72.8 months. Postoperatively, both clinical and functional outcomes significantly improved, as indicated by the Hip Society Score (HHS) and Knee Society Score (KSS). The overall success rate of the two-stage protocol was 89.5%. Complications that did not require revision occurred in 21% of cases. The most identified pathogen was methicillin-sensitive Staphylococcus aureus (MSSA). Difficult-to-treat (DTT) infections and post-traumatic etiology were identified as predictors of treatment failure in patients undergoing two-stage TJR for hip and knee SA.

CONCLUSIONS

Two-stage TJR in hip and knee SA demonstrated favorable clinical outcomes at mid-term follow-up. The procedure significantly improved functional scores and achieved a high success rate, while DTT infections and post-traumatic etiology were associated with a higher risk of treatment failure.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Medullary-Sparing Antibiotic Cement Articulating Spacer Reduces the Rate of Mechanical Complications in Advanced Septic Hip Arthritis: A Retrospective Cohort Study

Antibiotic cement articulating spacers eradicate infection during a two-stage revision for advanced septic hip arthritis (ASHA); however, mechanical complications have been reported. We hypothesized that the rate of mechanical complications would be lower in medullary-sparing (MS) than in non-medullary-sparing (n-MS) articulating spacers. A retrospective study of ASHA using n-MS or MS spacers was conducted between 1999 and 2019. The rate of mechanical complications and reoperation and risk factors for mechanical complications were analyzed. The cohort included 71 n-MS and 36 MS spacers. All patients were followed up for 2 years. The rate of spacer dislocation was lower in MS (0%) than in n-MS spacers (14.1%; p = 0.014). The reoperation rate for mechanical complications was lower in MS (0%) than in n-MS spacers (12.7%; p = 0.019). The rate of a diaphyseal stem during reimplantation was lower in MS (0%) than in n-MS spacers (19.4%; p = 0.002). The identified risk factors for n-MS spacer dislocation were postoperative under-restored femoral head diameter ≥3 mm, femoral offset ≥3 mm, and surgical volume (≤6 resection arthroplasties per year). Both spacers controlled infection. However, MS spacers had a lower spacer dislocation and reoperation rate and avoided the diaphyseal stem during reimplantation. We recommend using MS spacers to restore native femoral head diameter and femoral offset when ASHA is treated by surgeons with lower surgical volumes.

Medial gastrocnemius rotational flap for the reconstruction of extensor mechanism disruption in periprosthetic knee infections: a retrospective series with minimum two year follow-up

PURPOSE

Extensor mechanism disruption following total knee arthroplasty has a prevalence ranging from 0.3 to 3%. Its management is challenging, especially in case of associated infection of the prosthetic implant. Surgical options are limited due to the septic process, and the use of allograft or synthetic mesh are not recommended. The aim of this study was to report clinical outcomes, complications, survival, and surgical technique of medial gastrocnemius flap for the treatment of extensor mechanism disruptions associated with periprosthetic knee infection.

METHODS

This is a retrospective study from a prospectively collected arthroplasty registry from 2012 to 2019. Patients who received the gastrocnemius flap in the setting of a two-stage knee replacement for periprosthetic infection were included. Results of physical examination, Knee Society Score, Oxford Knee Score, and measurement of the range of motion registered pre-operatively were compared to those obtained at last follow-up. Survival was analysed through Kaplan-Meier curve.

RESULTS

A total of 15 patients were included, with a mean age of 63.4 years (range 36-77). The reconstruction of the extensor mechanism demonstrated a success rate of 73.3%. The mean extension lag at final follow-up was 7.5° (range, 0-30). The mean Knee Society Score and Oxford Knee Score improved from 29.0 (range, 21-36) and 17.5 (range, 13-22) respectively, to 82.9 (range, 74-89) and 36.0 (range, 33-39).

CONCLUSION

Medial gastrocnemius rotational flap is a reliable option for joint and limb salvage in case of periprosthetic knee infection associated with wide soft tissue degeneration and extensor mechanism disruption. The technique and surgical protocol presented in this study are reproducible and guaranteed good clinical outcomes and infection control.

Multiple organ failure and death caused by Staphylococcus aureus hip infection: A case report

Suppurative arthritis has an acute onset and mostly affects old people and children. Recently, the incidence of adult suppurative hip arthritis, as well as its serious consequences, has increased. The deep hip joint and surrounding hypertrophic muscle tissue limit physical examination. Furthermore, they may cause variable and atypical symptoms of suppurative hip arthritis, possibly inducing delayed diagnosis and treatment. This atypical presentation is uncommon, causing delayed diagnosis and treatment, thus worsening the outcomes. We herein report the case of a 58-year-old man with Staphylococcus aureus (S. aureus) septicemia and multiple organ failure due to left pyogenic arthritis of the hip. The patient's early symptoms were extremely atypical given that he only presented hip pain. Moreover, there was no obvious history of trauma or inflammatory manifestations, such as fever or local swelling, and laboratory examination results and imaging findings were atypical. However, the disease progressed rapidly, developing into systemic sepsis within a short period of time followed by multiple organ failure and death. Early diagnosis and effective treatment of S. aureus hip arthritis are essential to avoid poor outcomes.

Two-stage revision for periprosthetic joint infection in unicompartmental knee arthroplasty: clinical and radiological results

INTRODUCTION

Unicompartmental knee arthroplasty (UKA) has an infection rate of 0.1-0.8%. Despite the wide amount of literature about septic total knee arthroplasty management, few data are available for UKA infection treatment. The aim is to present the clinical and radiological outcomes along with complication rates of a series of septic UKA treated with two-stage exchange.

METHODS

We retrospectively reviewed 16 patient treated with staged UKA revision for infection between June 2015 and September 2019 in a single bone infection unit. The main demographic and surgical data were recorded. Clinical scores (VAS, KSS, OKS, postoperative ROM), radiological parameters (osseointegration, loosening and radiolucencies) and complications were reported. The mean follow-up was 33.5 ± 6.9 months.

RESULTS

Mean age at surgery was 68.5 ± 9.1. All but two were medial UKA. The mean number of previous surgeries was 2.9 ± 1.9. The mean ROM, VAS, KSS and OKS of the entire population improved significantly (p < 0.01). Radiological analysis did not show any migration or implant loosening. Ten constrained condylar and six posterior stabilized prosthesis were finally implanted. One intraoperative pathogen isolation was recorded and managed with suppressive therapy and good final outcome. The implant survivorship free from infection was 100% at the final follow-up. The overall survival rate for any reason of revision was 100% CONCLUSION: According to our results, staged revision represents a reliable ad effective option in delayed and late UKA infections. This technique provides optimal clinical and radiological results with acceptable complication rates. To the best of our knowledge, this represent the widest case series on infected UKA managed with two-stage exchange.

Management of septic arthritis of the hip joint in adults. A systematic review of the literature

BACKGROUND

The septic arthritis of the hip is a complex condition characterized by a variety of clinical presentations, a challenging diagnosis and different surgical treatment options, including arthroscopy, resection arthroplasty and one and two-stage total hip replacement. Each technique reports variable results in terms of infection eradication rate. The aim of this systematic review is to compare the most relevant studies available in current literature and to assess if a better treatment outcome can be predicted based on the microbiology, history, and type of infection (active vs quiescent) of each case.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA guidelines, including the studies dealing with the treatment of hip septic arthritis in adult patients. Electronic databases, namely the MEDLINE, Scopus, and Web of Science, were reviewed using a combination of following keywords "septic arthritis" AND "hip joint" OR "hip" AND "adult".

RESULTS

The total number of patients included in this review was 1236 (45% of which females), for 1238 hips. The most common pathogen isolated was Staphylococcus aureus in its Methicillin-sensitive variant ranging from 2 to 37% of cases. Negative cultures were the second most common finding. It was also differentiated the type of infection of the hip, 809 and 417 patients with active and quiescent hip infection, respectively, were analyzed. Eradication rates for two-stage revision arthroplasty ranged between 85 and 100%, for one-stage approach between 94 and 100%, while for arthroscopic debridement/lavage between 89 and 100%.

CONCLUSION

Staphylococcus aureus is the most common microorganism isolated followed by culture negative infections. Arthroscopic, one and two stage procedures can be effective in the treatment of hip septic arthritis when the indication is consistent with the type of infection retrieved.

LEVEL OF EVIDENCE

IV, therapeutic study.

Two-stage arthroplasty for septic arthritis of the hip and knee: A systematic review on infection control and clinical functional outcomes

INTRODUCTION

Septic arthritis of the native hip and knee joint poses particular challenges to orthopedic surgeons. Patients often suffer from several comorbidities, and it could be challenging to find a balance between infection control and adequate function. Two-stage arthroplasty has been addressed as a reliable solution, however the literature on the topic is composed of case series with small sample size. This systematic review aimed to analyze data on infection control and clinical functional outcomes of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee.

METHODS

An electronic search of studies published from January 1st, 2000, to June 1st, 2021, was conducted using eight different databases. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Revies and Meta-analysis two authors reviewed the available literature and reference lists to identify papers eligible for inclusion.

RESULTS

A total of 21 studies were included, involving 435 procedures. The mean age was 57.3 ± 6.2 (45.8-71.8) years. The mean follow-up was 53.7 ± 18.6 (12-86.7) months. The mean infection eradication was 93.3 ± 6.4%. Mean Harris Hip Score improved from 32.1 ± 10.6 (11.5-42.9) to 87.5 ± 5.7 (80.6-97.8). Mean Knee Society Score improved from 42.9 ± 7.6 (35.9-58.0) to 86.1 ± 5.4 (80.1-96.0).

CONCLUSIONS

Two-stage arthroplasty for hip and knee septic arthritis provided high infection control rate and excellent function. Further high-quality studies should be oriented on providing a validated algorithm for diagnosis and treatment of this condition.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.