Management of Periprosthetic Joint Infection: The More We Learn, the Less We Know

Clinical outcomes of two-stage revision arthroplasty using a spiked tibial cement spacer in infected total knee arthroplasty

PURPOSE

A tibial cement spacer (TCS) with spikes offers better initial stability than a conventional TCS and reduces spacer-related problems in two-stage revision total knee arthroplasty (R-TKA) for infection. We compared the clinical outcomes of two-stage revision arthroplasty for infected TKA using spiked TCS with that of conventional TCS.

METHODS

This retrospective cohort study included 29 patients who underwent two-stage revision arthroplasty using an articulating cement spacer and who could be followed up for at least one year. Group S comprised 14 patients using spiked TCS, whereas Group C comprised 15 patients using conventional TCS. Demographic data, the interval from first to second stage revision, motion arc, numerical rating scale (NRS), Knee Society (KS) score, serum levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and frequency of repeating the first-stage and infection recurrence after R-TKA between the groups were analyzed.

RESULTS

No significant differences were observed in the female ratio and mean age between both groups. The mean interval between the first and second stage revision was significantly shorter in Group S than in Group C. The mean motion arc was significantly larger in Group S than in Group C. The mean NRS was significantly lower in Group S than in Group C. The mean KS score in Group S was significantly higher than that in Group C. Serum ESR and CRP levels did not differ between the groups. The frequency of repeating the first stage was lower in Group S than in Group C. However, the recurrence rate after R-TKA was higher in Group S than in Group C.

CONCLUSION

Compared with conventional TCS, spiked TCS shortened the period until R-TKA and improved pain and function levels. However, no significant difference existed in the rate of infection recurrence after R-TKA.

The Impact of Culture Negativity on the Outcomes of Revision Total Knee Arthroplasty for Chronic PJI

Culture-positive (CP) and culture-negative (CN) periprosthetic joint infections (PJI) remain a crucial area of research; however, current studies comparing these infections rely on unstandardized outcome reporting tools. Our study aimed to compare the outcomes of two-stage revision of CP and CN PJI using the standardized Musculoskeletal Infection Society (MSIS) outcome reporting tool. We retrospectively reviewed 138 patients who were diagnosed with PJI and indicated for two-stage revision total knee arthroplasty (rTKA). The majority of patients in both CP and CN cohorts achieved infection control without the need for reoperation (54.1% and 62.5%, respectively). There was a significant difference in the overall distribution of MSIS outcomes (p = 0.043), with a significantly greater rate of CN patients falling into Tier 1 (infection control without the use of suppressive antibiotics) (52.5% versus 29.6%, p = 0.011). There was also a significant difference in the distribution of septic versus aseptic reoperations after 2nd stage (p = 0.013), with more CP reoperations being septic and more CN reoperations being aseptic. The duration from first to second stage was significantly shorter in the CN cohort (p = 0.002). While overall infection control was similar between cohorts, these data suggest that the outcomes of two-stage rTKA are favorable in cases of CN PJI.

Evaluating Modern Spacer Options and Outcomes in Revision Hip Arthroplasty

BACKGROUND

A 2-stage revision continues to be the standard treatment for periprosthetic joint infection (PJI) in hip arthroplasty. The use of "functional" spacers may allow patients to return to daily living while optimizing their health for revision surgery. We aimed to evaluate the clinical outcomes of different spacer types regarding infection eradication, mechanical complications, and functional outcomes.

METHODS

Patients who have complete Musculoskeletal Infection Society criteria for diagnosis of PJI that underwent one-stage or 2-stage revision were queried in an institutional surgical database between 2002 and 2022. Out of 286 patients, 210 met our inclusion criteria and were retrospectively reviewed for demographics, laboratory values, functional and patient-reported outcomes, and subsequent revisions. The study population had 54.3% women, a mean age of 61 years old, and a mean follow-up of 3.7 ± 3.2 years. There was no difference between age, body mass index, or Charlson Comorbidity Index scores between each cohort. Spacers were categorized as nonfunctional static, nonfunctional articulating, or functional articulating. Functional spacers were defined as those that allowed full weight bearing with no restrictions. Delphi criteria were used to define revision success, and failure was defined as a recurrent or persistent infection following definitive surgery.

RESULTS

There was a significantly lower reoperation rate after a definitive implant in the functional articulating cohort (P = .003), with a trending higher infection eradication rate and a lower rate of spacer failure compared to the nonfunctional spacer cohort. At 5 years, functional articulating spacers had a 94.1% survivorship rate, nonfunctional articulating spacers had an 81.2% survival rate, and nonfunctional static spacers had a 71.4% survival rate. In the functional articulating spacer cohort, 14.6% had yet to get reimplanted, with an average follow-up time of 1.4 years.

CONCLUSIONS

Within this large cohort of similar demographics, functional articulating spacers may result in better clinical outcomes and infection eradication during 2-stage revision arthroplasty for PJI.

Time-Dependent Prediction Models for Individual Prognosis of Chronic Postsurgical Pain following Knee Replacement Based on an Extensive Multivariable Data Set

(1) Background: Clinically useful prediction models for chronic postsurgical pain (CPSP) in knee replacement (TKA) are lacking. (2) Methods: In our prospective, multicenter study, a wide-ranging set of 91 variables was collected from 933 TKA patients at eight time points up to one year after surgery. Based on this extensive data pool, simple and complex prediction models were calculated for the preoperative time point and for 6 months after surgery, using least absolute shrinkage and selection operator (LASSO) 1se and LASSO min, respectively. (3) Results: Using preoperative data only, LASSO 1se selected age, the Revised Life Orientation Test on pessimism, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-subscore pain and the Timed "Up and Go" Test for prediction, resulting in an area under the curve (AUC) of 0.617 and a Brier score of 0.201, expressing low predictive power only. Using data up to 6 months after surgery, LASSO 1se included preoperative Patient Health Questionnaire-4, Knee Injury and Osteoarthritis Outcome Score (KOOS)-subscore pain (pain) 3 months after surgery (month), WOMAC pain 3 and 6 months, KOOS subscore symptoms 6 months, KOOS subscore sport 6 months and KOOS subscore Quality of Life 6 months. This improved the predictive power to an intermediate one (AUC 0.755, Brier score 0.168). More complex models computed using LASSO min did little to further improve the strength of prediction. (4) Conclusions: Even using multiple variables and complex calculation methods, the possibility of individual prediction of CPSP after TKA remains limited.

Description of surgical treatment methods of hip and knee periprosthetic joint infections in the Chinese mainland: a national multi-centre survey

PURPOSE

Periprosthetic joint infection (PJI) is a serious hip and knee arthroplasty complication. Despite the increased incidence of primary joint replacements, there is no clear guideline for treating PJI in the Chinese mainland yet. We aim to measure the current situation and basis for surgical treatment methods of PJI in major orthopaedic hospitals in the Chinese mainland.

METHODS

We conducted a national survey on PJI treatment in Mainland China. Forty-one top arthroplasty centers were included, with 82.9% (34/41) response rate. The data were analyzed using Microsoft Excel version 20.0 and described as numbers and percentages.

RESULTS

For acute infections, prosthesis-preserving procedures (DAIR) are used in all centres. For hip and knee PJI, 20.5% (7/34) and 35% (12/34) of the centres used a one-stage exchange. If applied, this treatment will necessitate the previous patients' selection for a satisfactory outcome. All centres execute the two-stage exchange. Between phases, the majority of centres implant a cemented spacer. Revisions for infected hips included 21 (4.3%) cases of DAIR, 95 (19.9%) cases of single-stage exchange, 362 (75.2%) cases of two-stage exchange, and 2 (0.007%) cases of hip dissection. Revisions for infected knee comprised 88 (19.0%) cases of DAIR, 48 (10.3%) cases of single-stage exchange, 324 (69.8%) cases of two-stage exchange, and 5 (0.02%) cases of knee fusion.

CONCLUSIONS

The centers do not have a uniform PJI standard. Most patients have two-stage revision with a cemented spacer in China. These concepts can help establish treatment guidelines.

Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection

The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose−response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose−response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.

Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures

INTRODUCTION

Evidence demonstrates comparable clinical outcomes across the various surgical approaches to primary total hip arthroplasty (THA). However, high-quality contemporary data regarding periprosthetic joint infection (PJI) risk between direct anterior approach (DAA) and other (THA) approaches is lacking. This systematic review and meta-analysis evaluated PJI rates reported in the literature between the DAA and other approaches.

MATERIALS AND METHODS

Five online databases were queried for all studies published from January 1st, 2000 through February 17th, 2021 that reported PJI rates between DAA and other surgical approaches. Studies reporting on primary THAs for osteoarthritis (OA) and that included PJI rates segregated by surgical approach were included. Articles reporting on revision THA, alternative THA etiologies, or minimally invasive techniques were excluded. Mantel-Haenszel (M-H) models were utilized to evaluate the pooled effect of surgical approach on infection rates. Validated risk of bias and methodological quality assessment tools were applied to each study. Multiple sensitivity analyses were conducted to evaluate the robustness of analyses.

RESULTS

28 articles reporting on 653,633 primary THAs were included. No differences were found between DAA cohorts and combined other approaches (OR: 0.95; 95% CI 0.74-1.21; p = 0.67) as well as segregated anterolateral approach cohorts (OR: 0.82, 95% CI 0.64-1.06; p = 0.13). However, DAA patients had a significantly reduced risk of infection compared to those undergoing posterior (OR: 0.66, 95% CI 0.58-0.74; p < 0.0001) and direct lateral (OR: 0.56, 95% CI 0.48-0.65; p < 0.00001) approaches.

CONCLUSION

The DAA to primary THA had comparable or lower PJI risk when compared to other contemporary approaches. The results of the most up-to-date evidence available serve to encourage adult reconstruction surgeons who have already adopted the DAA. Additionally, orthopaedic surgeons considering adoption or use of the direct anterior approach for other reasons should not be dissuaded over theoretical concern for a general increase in the risk of PJI.

LEVEL OF EVIDENCE

Level III.

Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges

The uses of implantable medical devices are safer and more common since sterilization methods and techniques were established a century ago; however, device-associated infections (DAIs) are still frequent and becoming a leading complication as the number of medical device implantations keeps increasing. This urges the world to develop instructive prevention and treatment strategies for DAIs, boosting the studies on the design of antibacterial surfaces. Every year, studies associated with DAIs yield thousands of publications, which here are categorized into four groups, i.e., antibacterial surfaces with long-term efficacy, cell-selective capability, tailored responsiveness, and immune-instructive actions. These innovations are promising in advancing the solution to DAIs; whereas most of these are normally quite preliminary “proof of concept” studies lacking exact clinical scopes. To help identify the flaws of our current antibacterial designs, clinical features of DAIs are highlighted. These include unpredictable onset, site-specific incidence, and possibly involving multiple and resistant pathogenic strains. The key point we delivered is antibacterial designs should meet the specific requirements of the primary functions defined by the “intended use” of an implantable medical device. This review intends to help comprehend the complex relationship between the device, pathogens, and the host, and figure out future directions for improving the quality of antibacterial designs and promoting clinical translations.

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

Contemporary 2-Stage Treatment of Periprosthetic Hip Infection with Evidence-Based Standardized Protocols Yields Excellent Results: Caveats and Recommendations

BACKGROUND

This study quantified the effectiveness of contemporary and evidence-based standardized 2-stage treatment for periprosthetic hip infection. Findings illustrate potential limitations of criticisms of 2-stage protocols and potential consequences of adopting single-stage protocols before definitive data are available.

METHODS

Fifty-four consecutive hips treated with 2-stage resection and reimplantation were retrospectively reviewed. Standardized protocols were adhered to including implant resection, meticulous surgical debridement, antibiotic spacer, 6-week intravenous antibiotics, a 2-week drug holiday, and laboratory assessment of infection eradication before reimplantation. After reimplantation, patients were placed on prophylactic intravenous antibiotics until discharge and discharged on oral antibiotics for a minimum of 7 days until intraoperative cultures were final. Successful treatment was defined per Delphi-based International Multidisciplinary Consensus.

RESULTS

The overall treatment success rate was 95.7% (44 of 46 cases) with mean infection-free survivorship of 67.2 (range, 23.8-106.4) months. Success rates were 100% for early and acute hematogenous infections regardless of host type and 100% for chronic infections in uncompromised hosts. 95% (19/20) of chronic infections in compromised hosts and 83.3% (5/6) of chronic infections in significantly compromised hosts were successfully treated. About 4% of primary hips and 20% of revision hips required repeat debridement and spacer exchange after initial resection. No patients died because of treatment.

CONCLUSION

Details from this consecutive series of patients undergoing 2-stage treatment for hip infection suggest that some criticisms of 2-stage treatment as well as some arguments in support of single-stage treatment may be overstated. Promotion and uncritical adoption of single-stage treatment protocols are discouraged until further and more definitive data exist.

Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2030

BACKGROUND

As the incidence of primary total joint arthroplasty rises in the United States, it is important to investigate how this will impact rates of revision arthroplasty. The purpose of this study was to analyze the incidence and future projections of revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) to 2030. Anticipating surgical volume will aid surgeons in designing protocols to efficiently and effectively perform rTHA/rTKA.

METHODS

The national inpatient sample was queried from 2002 to 2014 for all rTHA/rTKA. Using previously validated measures, Poisson and linear regression analyses were performed to project annual incidence of rTHA/rTKA to 2030, with subgroup analyses on modes of failure and age.

RESULTS

In 2014, there were 50,220 rTHAs and 72,100 rTKAs. From 2014 to 2030, rTHA incidence is projected to increase by between 43% and 70%, whereas rTKA incidence is projected to increase by between 78% and 182%. The 55-64 and 65-74 age groups increased in revision incidence during the study period, whereas 75-84 age group decreased in incidence. For rTKA, infection and aseptic loosening are the 2 most common modes of failure, whereas periprosthetic fracture and infection are most common for rTHA.

CONCLUSION

The incidence of rTHA/rTKA is projected to increase, particularly in young patients and for infection. Given the known risk factor profiles and advanced costs associated with revision arthroplasty, our projections should encourage institutions to generate revision-specific protocols to promote safe pathways for cost-effective care that is commensurate with current value-based health care trends.

LEVEL OF EVIDENCE

IV.

Total Elbow Arthroplasty: Clinical Outcomes, Complications, and Revision Surgery

Total elbow arthroplasty is a common surgical procedure used in the management of advanced rheumatoid arthritis, posttraumatic arthritis, osteoarthritis, and unfixable fracture in elderly patients. Total elbow prostheses have evolved over the years and now include the linked, unlinked, and convertible types. However, long-term complications, including infection, aseptic loosening, instability, and periprosthetic fracture, remain a challenge. Here, we introduce each type of implant and evaluate clinical outcomes and complications by reviewing the previous literature.

2019 Frank Stinchfield Award: A comparison of prosthetic joint infection rates between direct anterior and non-anterior approach total hip arthroplasty

AIMS

We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution.

PATIENTS AND METHODS

A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, sd 12.3) and 28.8 kg/m² (13.3 to 57.6, sd 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols.

RESULTS

There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period.

CONCLUSION

We found a higher rate of PJI in DA versus NA approaches. Infection prevention protocols such as use of aspirin, dilute povidone-iodine lavage, vancomycin powder, and Gram-negative coverage may have been positively associated with diminished PJI rates observed for all approaches over time. Cite this article: Bone Joint J 2019;101-B(6 Supple B):2-8.

Bi-functional titanium-polydopamine-zinc coatings for infection inhibition and enhanced osseointegration

The ideal orthopedic implant coating is expected to both inhibit microbial infection and promote osseointegration. In this study, Zn ions were immobilized on a Ti substrate via a polydopamine (PDA) chemical surface modification to prepare Ti-PDA-Zn coatings. Scanning electron microscopy (SEM), atomic force microscopy (AFM), energy-dispersive X-ray spectroscope (EDS), X-ray photoelectron spectroscopy (XPS), contact analysis system, and inductively coupled plasma atomic emission spectrometry (ICP-AES) were used to analyze the morphology, composition, wettability, and zinc ions release of the coatings. The Ti-PDA-Zn coatings demonstrated excellent antibacterial activities in vitro against both Staphylococcus aureus and Escherichia coli. The coatings additionally displayed good biocompatibility, as confirmed by cytoskeletal observations and cell viability assays. Furthermore, the in vivo results confirmed the excellent antibacterial properties and improved osseointegration capability of the Ti-PDA-Zn coating in the presence of S. aureus. The present findings indicate that the Ti-PDA-Zn coatings prepared herein have potential application in orthopedic implantation.

The ideal orthopedic implant coating is expected to both inhibit microbial infection and promote osseointegration.

Novel Insights into Staphylococcus aureus Deep Bone Infections: the Involvement of Osteocytes

Periprosthetic joint infection (PJI) is a potentially devastating complication of orthopedic joint replacement surgery. PJI with associated osteomyelitis is particularly problematic and difficult to cure. Whether viable osteocytes, the predominant cell type in mineralized bone tissue, have a role in these infections is not clear, although their involvement might contribute to the difficulty in detecting and clearing PJI. Here, using Staphylococcus aureus, the most common pathogen in PJI, we demonstrate intracellular infection of human-osteocyte-like cells in vitro and S. aureus adaptation by forming quasi-dormant small-colony variants (SCVs). Consistent patterns of host gene expression were observed between in vitro-infected osteocyte-like cultures, an ex vivo human bone infection model, and bone samples obtained from PJI patients. Finally, we confirm S. aureus infection of osteocytes in clinical cases of PJI. Our findings are consistent with osteocyte infection being a feature of human PJI and suggest that this cell type may provide a reservoir for silent or persistent infection. We suggest that elucidating the molecular/cellular mechanism(s) of osteocyte-bacterium interactions will contribute to better understanding of PJI and osteomyelitis, improved pathogen detection, and treatment.IMPORTANCE Periprosthetic joint infections (PJIs) are increasing and are recognized as one of the most common modes of failure of joint replacements. Osteomyelitis arising from PJI is challenging to treat and difficult to cure and increases patient mortality 5-fold. Staphylococcus aureus is the most common pathogen causing PJI. PJI can have subtle symptoms and lie dormant or go undiagnosed for many years, suggesting persistent bacterial infection. Osteocytes, the major bone cell type, reside in bony caves and tunnels, the lacuno-canalicular system. We report here that S. aureus can infect and reside in human osteocytes without causing cell death both experimentally and in bone samples from patients with PJI. We demonstrate that osteocytes respond to infection by the differential regulation of a large number of genes. S. aureus adapts during intracellular infection of osteocytes by adopting the quasi-dormant small-colony variant (SCV) lifestyle, which might contribute to persistent or silent infection. Our findings shed new light on the etiology of PJI and osteomyelitis in general.

Managing an Acute and Chronic Periprosthetic Infection

A case report of a 65-year-old female with a history of right total hip arthroplasty (THA) in 2007 and left THA in 2009 was presented. She consulted with our institution for the first time, on December 2013, for right hip pain and fistula on the THA incision. It was managed as a chronic infection, so a two-stage revision was performed. First-time intraoperative cultures were positive for Staphylococcus aureus (3/5) and Proteus mirabilis (2/5). Three weeks after the second half of the review, it evolved with acute fever and pain in relation to right hip. No antibiotics were used, arthrocentesis was performed, and a coagulase-negative staphylococci multisensible was isolated at the 5th day. Since the germ was different from the first revision, it was decided to perform a one-stage revision. One year after the first review, the patient has no local signs of infection and presents ESV and RPC in normal limits. The indication and management of periprosthetic infections are discussed.

Mussel-inspired deposition of copper on titanium for bacterial inhibition and enhanced osseointegration in a periprosthetic infection model

Periprosthetic infection represents one of the most devastating complications in orthopedic surgeries.