General Assembly, Prevention, Host Related Local: Proceedings of International Consensus on Orthopedic Infections

Do urinary tract infections affect the rate of periprosthetic joint infections in patients who underwent arthroplasty surgery? A systematic review and meta-analysis

Periprosthetic joint infection (PJI) is a significant issue in orthopedic surgery. Urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) have been identified as potential causes of PJI; however, evidence is inconclusive. Understanding these relationships is critical for improving therapy and patient outcomes. A systematic review was performed by conducting searches from PubMed, EBSCO, ProQuest, and manual searching with adherence to the Preferred Reporting Items for Systematic Review and Meta-Analysis 2020 guideline. Studies that reported UTI/ASB and PJI were included. Meta-analysis was conducted using a random-effects model using RevMan 5.4 software. A total of 14 studies were included with UTIs and ASB showed an overall association with increased risk of PJI (odds ratio [OR]: 1.84, 95% confidence interval [CI]: 1.14-2.99, P = 0.01). However, subgroup analysis for UTIs and ASB was not significant. Further analysis of UTIs in total hip arthroplasty (THA) surgery showed a significant association (OR: 1.76, 95% CI: 1.57-1.96) with PJI. Preoperative UTIs timing between 0 and 2 weeks before surgery showed an increased risk of PJI (OR: 1.45, 95% CI: 1.35-1.55). Antibiotic treatment in ASB did not significantly impact PJI rates. Urine and PJI sample cultures in four studies showed no correlation of microorganisms between the two sites. According to recent evidence, a statistically significant association was found between UTIs and PJI in patients who underwent THA surgery. However, ASB did not yield significant results in relation to PJI. These results should be supported by larger and well-designed studies to make proper clinical suggestion in future. For further research, it is recommended to adopt standardized criteria for outcome measurement and to involve larger sample sizes to enhance the reliability and generalizability of findings.

Outcomes of Total Hip Arthroplasty Performed for HIV-Associated Osteonecrosis in China: A Retrospective Cohort Study

BACKGROUND

In the post-epidemic era, Acquired Immune Deficiency Syndrome (AIDS) remains one of the most prevalent and detrimental infectious diseases worldwide. The incidence of osteonecrosis of the femoral head (ONFH) in AIDS patients is 100 times higher than that in healthy individuals. Although Total Hip Arthroplasty (THA) is ultimately necessary for most patients, there is still a dearth of evidence regarding its safety and efficacy in Chinese AIDS patients.

METHODS

The clinical data of 49 patients who met the inclusion and exclusion criteria were retrospectively analyzed. Simultaneously, we categorized patients whose hemoglobin and albumin met a specific threshold as the optimized group and performed group comparisons.

RESULTS

There are statistical differences in Harris score and VAS score pre- and post-operation, with a low overall complication rate. Notably, no disparities were observed between the optimized group and the partial optimized group in terms of overall conditions, laboratory examination indicators, severity of ONFH, surgical outcomes, surgical complications, pain perception or functional limitations. Furthermore, no correlation was found between CD4+ T lymphocytes and hemoglobin levels, albumin levels, white blood cell count, or platelet count.

CONCLUSION

THA is safe and effective in Chinese AIDS patients with ONFH. However, optimal treatment has limited efficacy in AIDS patients undergoing THA for ONFH. The reconsideration and evaluation of the predictive value of CD4+ T lymphocytes for postoperative complications in joint replacement procedures is warranted.

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

BACKGROUND

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).

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Comparative analysis of pathogen distribution in patients with fracture-related infection and periprosthetic joint infection: a retrospective study

BACKGROUND

The purpose of this study is to investigate the microbial patterns of periprosthetic joint infection (PJI) and fracture-related infection (FRI), and guide for the formulation of more accurate empirical antimicrobial regimens based on the differences in pathogen distribution.

METHODS

A comparative analysis of pathogen distribution was conducted between 153 patients (76 with PJI and 77 with FRI). Predicted analyses against isolated pathogens from two cohorts were conducted to evaluate the best expected efficacy of empirical antimicrobial regimens (imipenem + vancomycin, ciprofloxacin + vancomycin, and piperacillin/tazobactam + vancomycin).

RESULTS

Our study found significant differences in pathogen distribution between the PJI and FRI cohorts. Staphylococci (61.3% vs. 31.9%, p = 0.001) and Gram-negative bacilli (GNB, 26.7% vs. 56.4%, p < 0.001) were responsible for the majority of infections both in the PJI and FRI cohorts, and their distribution in the two cohorts showed a significant difference (p < 0.001). Multi-drug resistant organisms (MDRO) were more frequently detected in the FRI cohort (29.3% vs. 44.7%, p = 0.041), while methicillin-resistant coagulase-negative Staphylococci (MRCoNS, 26.7% vs. 8.5%, p = 0.002) and Canidia albicans (8.0% vs. 1.1%, p = 0.045) were more frequently detected in the PJI cohort. Enterobacter spp. and Acinetobacter baumannii were detected only in the FRI cohort (11.7% and 8.5%, respectively).

CONCLUSIONS

Staphylococci and GNB were responsible for the majority of infections in both PJI and FRI. Empirical antimicrobial therapy should focus on the coverage of Staphylococci in PJI and GNB in FRI, and infections caused by MDROs should be more vigilant in FRI, while the high incidence of MRCoNS in PJI should be noted, which could guide for the formulation of more accurate empirical antimicrobial regimens. Targeted therapy for FRI caused by A. baumannii and PJI caused by C. albicans needs to be further investigated. Our study reports significant differences in pathogen distribution between the two infections and provides clinical evidence for studies on the mechanism of implant-associated infection.

The Timing of Preoperative Urinary Tract Infection Influences the Risk of Prosthetic Joint Infection Following Primary Total Hip and Knee Arthroplasty

BACKGROUND

The importance of preoperative urinary tract infection (UTI) in total hip and knee arthroplasty (THA and TKA) is controversial. The purpose of this study was to investigate the timing of preoperative UTI diagnosis and association with prosthetic joint infection (PJI) and determine if antibiotics impact this risk.

METHODS

A national database was used to analyze patients undergoing THA and TKA diagnosed with a preoperative UTI. Timing of diagnosis was categorized by 1-week intervals prior to surgery. Matched cohorts without UTI were collected, and PJI rates within 2 years of surgery were compared. Patients who received antibiotic prescriptions were identified and compared to no prescription.

RESULTS

Preoperative UTI within 1 week of TKA was associated with higher rates of PJI (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.26-1.43, P < .001). Preoperative UTI within 1 week of THA (OR 1.56, 95% CI 1.44-1.68, P < .001) and between 1-2 weeks prior to THA (OR 1.12, 95% CI 1.02-1.22, P = .022) was associated with significantly higher rates of PJI. UTI diagnosis at any other time interval did not reach statistical significance. Antibiotic prescription was not associated with lower rates of PJI.

CONCLUSION

Patients with preoperative UTI within 1 week of TKA or within 2 weeks of THA have an increased risk of postoperative PJI. Antibiotics do not appear to mitigate risk.

LEVEL OF EVIDENCE

Level III; Retrospective, database comparison.

Periprosthetic Knee Infection - Part 1: Risk Factors, Classification and Diagnosis

Infection is one of the most feared complications in the postoperative period of knee arthroplasties. With the progressive aging of the population and the increased incidence of degenerative joint diseases, there is an exponential increase in the number of arthroplasties performed and, consequently, in the number of postoperative infections. The diagnosis of these should follow a hierarchical protocol, with well-defined criteria, which lead to diagnostic conclusion, thus guiding the most appropriate treatment. The aim of the present update article is to present the main risk factors, classifications and, mainly, to guide diagnostic investigation in an organized manner.

An Orthopedic Surgeon's Dental Examination: Reducing Unnecessary Delays in Joint Replacement Surgery for Marginalized Patients in a Safety Net Hospital System

Background

Selective dental clearance before total joint arthroplasty (TJA) has been proposed; however, effective strategies of carrying out this practice are lacking. This study aims to determine the positive predictive value (PPV) of a novel oral examination performed by an orthopedic surgeon to better direct limited resources for marginalized patients in a safety net hospital system.

Methods

A retrospective review was conducted on 105 consecutive patients who had an oral examination performed by a single surgeon before elective TJA. Patients who screened negative proceeded to surgery without further formal dental clearance. Patients who screened positive underwent formal examination/intervention by a dentist before surgery. The rate of correct referral that resulted in patients undergoing an oral surgical intervention was determined. Complications during a minimum 90-day postoperative follow-up period were collected and compared.

Results

Thirty patients (28.6%) screened positive while 75 patients (71.4%) screened negative and proceeded to surgery without referral. The PPV of the screening test was high, with 73.3% of patients receiving a major surgical oral intervention before TJA. Patients sent for formal referral required 89.1 more days to receive their surgery than those that screened negative (54.9 days ± 4.24 vs 144.0 days ± 82.4, P < .001).

Conclusion

An orthopedic surgeon’s oral examination demonstrates a high PPV to identify high-risk patients in need of an oral surgical intervention before TJA. This provides a unique solution regarding over-referral for preoperative dental clearance and avoids delays for marginalized patients considering elective TJA in a safety net hospital system.

Preoperative optimization to prevent periprosthetic joint infection in at-risk patients

Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.

Urinary retention after total joint arthroplasty of hip and knee: Systematic review

PURPOSE

Postoperative urinary retention (POUR) is a common complication after total joint arthroplasties (TJAs). The POUR is managed with urinary catheterization, which is associated with a risk of urinary tract infection and subsequent periprosthetic joint infection. The purpose of this review was to afford a comprehensive understanding of POUR and its management.

METHODS

We identified 15 original articles concerning POUR after TJA, which were published from January 2010 to February 2019. The diagnostic method, incidence, risk factors, and management of POUR of the 15 studies were reviewed.

RESULTS

The incidence of POUR was ranged from 4.1% to 46.3%. Ultrasound was used for the detection of POUR among the total of the 15 studies. The following factors of old age, male gender, benign prostatic hypertrophy, history of urinary retention, spinal/epidural anesthesia, excessive fluid administration, patient-controlled analgesia, the use of opiates, underlying comorbidities, and poor American Society of Anesthesiologists (ASA) grade were risk factors for POUR. Most of the studies did not use indwelling catheterization during surgery. The POUR patients were managed with intermittent catheterization. The most common volume criterion for bladder catheterization was 400 mL. In inevitable use of an indwelling catheter, it should be removed within 48 h.

CONCLUSIONS

This review provided an up-to-date guide for the detection and management of POUR.

LEVEL OF EVIDENCE

Level III.

Minimizing Penile Prosthesis Implant Infection: What Can We Learn From Orthopedic Surgery?

The implantation of penile protheses for the surgical treatment of erectile dysfunction has risen in popularity over the past several decades. Considerable advances have been made in surgical protocol and device design, specifically targeting infection prevention. Despite these efforts, device infection remains a critical problem, which causes significant physical and emotional burden to the patient. The aim of this review is to broaden the discussion of best practices by not only examining practices in urology, but additionally delving into the field of orthopedic surgery to identify techniques and approaches that may be applied to penile prothesis surgery.

Impact of dental clearance on total joint arthroplasty: A systematic review

Many orthopedic surgeons require that their patients obtain dental clearance before elective total joint arthroplasty (TJA). However, there is no consensus substantiating the practice. To this end, a systematic review on the prevalence of dental pathology in TJA patients, risk factors for failing dental screening, and impact of dental evaluations was performed. Literature was sourced from PubMed and Scopus databases. Six papers were sourced from the initial search, one study was extracted from the references of the original six manuscripts, and one new publication was retrieved from a second search conducted after the first. The prevalence of dental pathology ranged from 8.8% to 29.4% across studies. Two of four papers reported lower than average or improvements in post-operative infection with pre-operative dental evaluations while two found no such association. There is insufficient evidence to support universal dental clearance before TJA.

Should a Urinary Tract Infection Be Treated before a Total Joint Arthroplasty?

Periprosthetic joint infection (PJI) is one of the most serious complications after total joint arthroplasty (TJA). The prevalence of urinary tract infection (UTI) is common, particularly among elderly women, a group for whom TJA may be required. The association between preoperative UTI and increased risk of PJI after TJA is unclear. We reviewed key articles concerning the relationship between UTIs and PJI, and summarized recommendations of international consensus on PJI, which was established in Philadelphia in July of 2018. In addition, we distinguish between symptomatic UTI and asymptomatic bacteriuria, because their causative effects on PJI are quite different.