Pyogenic Arthritis of the Fingers and the Wrist: Can We Shorten Antimicrobial Treatment Duration?

Early Intervention in Septic Arthritis of the Hand, Optimizing Patient Outcomes in Hand Infections-A Five-Year Retrospective Study

Background and Objectives: Hand septic arthritis is a potentially debilitating condition that can significantly affect patient functionality and quality of life. Understanding the demographic, clinical, and microbiological characteristics of this condition is crucial for its effective treatment and management. This study aimed to analyze the demographic and clinical profiles of patients with hand septic arthritis, to identify common microbial pathogens, and to evaluate the impact of various factors on clinical course and treatment outcomes. Material and Methods: This cross-sectional retrospective study examined patients diagnosed with septic arthritis of the hand, focusing on their demographic data, clinical presentation, causative organisms, treatment methods, and outcomes. Data on age, sex, cause of infection, affected sites, surgical interventions, microbiological findings, and patient outcomes were also collected. Results: This study found a higher prevalence of septic arthritis in males and identified bite as the predominant cause. Staphylococcus aureus is the most common pathogen. A large number of patients did not exhibit bacterial growth, and bacterial resistance did not significantly affect the outcome. Outcomes were statistically influenced by the timing of medical presentation and the presence of comorbidities. Conclusions: Early diagnosis and intervention are critical for effective management of hand septic arthritis. This study underscores the need for a comprehensive approach that considers patient demographic and clinical characteristics to optimize treatment outcomes. Awareness and preventive measures are essential to reduce the incidence and severity of this condition.

Management of the Septic Wrist: A Systematic Review of Etiology and Therapeutic Strategies

Septic arthritis of the wrist can have severe deleterious effects on cartilage and bone if not promptly addressed. Expedient diagnosis and early medical intervention are important. The most effective strategy involves immediate arthrocentesis of the infected joint, enabling precise antibiotic selection based on joint fluid analysis. Diagnostic imaging is important in excluding fractures and identifying abscesses. This review explores the etiologic factors underlying septic wrist joint, identifying risk factors, and delineating optimal diagnosis and treatment approaches. The overarching goal is to impart valuable insights and guidance in the management of septic wrist joint, ensuring the highest quality patient care and optimal clinical outcomes.

Techniques for Continuous Catheter Irrigation of a Septic Metacarpophalangeal Joint

Septic arthritis of the metacarpophalangeal joint (MCPJ) compromises 9% of hand infections in Singapore. Common surgical treatment is open arthrotomy and joint washout. The wound is often left open for drainage postoperatively. Repeated debridement and secondary closure are frequently needed after the index surgery. We describe a method of continuous catheter irrigation of septic MCPJ joint using an infant feeding catheter. This method provides great infection clearance to avoid repeated debridement and allows primary closure of the wound to avoid secondary closure. This method also significantly reduces postoperative pain so that to facilitate early mobilization of the joint, which is crucial for functional recovery. We illustrate the techniques of this procedure and key points of postoperative management in the ward with case examples to demonstrate its simplicity, safety, and efficacy in treating MCPJ septic arthritis.

Managing Small Joint Septic Arthritis of the Hand

Background: Current guidance for the management of septic arthritis is limited to large joints and, therefore, unspecific to the small joints of the hand, which may present differently, require different diagnostic approaches, and have different complications. The aim of this article was to review current treatment trends for the management of small joint septic arthritis (SJSA) of the hand and offer guidelines for its management. Methods: A systematic review was carried out according to PRISMA guidelines and a survey distributed to Fellows of the British Society for Surgery of the Hand to establish expert opinion. The review and survey were combined to present a set of specific SJSA of the hand infection guidelines. Results: All 20 included studies recommended physical drainage of infected joint fluid; subsequent lavage and early antibiotic therapy, with physiotherapist-guided joint mobilisation. Statistical analysis of the 77 responses to our survey revealed that (in order of preference) the diagnosis was made by history and examination, blood tests, joint aspiration and vital signs; and for interventions: joint elevation and intravenous antibiotics; then joint washout repeated within 48 hours, if necessary. Conclusions: Small joint infection differs from large joint infection because it is difficult to obtain joint aspirate without damaging or opening the joint. We, therefore, recommend utilising exclusion blood tests, imaging and the clinical picture to establish the diagnosis and implement early treatment and rehabilitation. Level of Evidence: Level III.

Renal disease and diabetes increase the risk of failed outpatient management of cellulitic hand infections: a retrospective cohort study

BACKGROUND

Hand infections are heterogeneous, and some may undergo successful outpatient management. There are no strict guidelines for determining which patients will likely require inpatient admission for successful treatment, and many patients succeed with outpatient therapy. We sought to determine risk factors for failed outpatient management of cellulitic hand infections.

METHODS

We performed a retrospective review of patients who presented to the Emergency Department (ED) for hand cellulitic infections over five years, from 2014 to 2019. Vital signs, lab markers, Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Measure (ECM), and antibiotic use were investigated. Discharge from the ED without subsequent admission was considered an outpatient success, while admission within 30 days of the prior visit was considered a failure. Continuous variables were compared with Welch's t test, and categorical data with Fisher's exact tests. Multivariable logistic regression was performed on comorbidities. Multiple testing adjustment was performed on p-values to generate q-values.

RESULTS

Outpatient management was attempted for 1,193 patients. 31 (2.6%) infections failed treatment, and 1,162 (97.4%) infections succeeded. Attempted outpatient treatment was 97.4% successful. Multivariable analysis demonstrated higher odds of failure with renal failure according to both CCI (OR 10.2, p < 0.001, q = 0.002) and ECM (OR 12.63, p = 0.003, q = 0.01) and with diabetes with complications according to the CCI (OR 18.29, p = 0.021, q = 0.032).

CONCLUSIONS

Outpatient treatment failure was higher in patients with renal failure and complicated diabetes. These patients require a high index of suspicion for outpatient failure. These comorbidities should influence consideration for inpatient therapy though most patients can undergo successful treatment as outpatients.

LEVEL OF EVIDENCE

Level III.

SPILF update on bacterial arthritis in adults and children

In 2020 the French Society of Rhumatology (SFR) published an update of the 1990 recommendations for management of bacterial arthritis in adults. While we (French ID Society, SPILF) totally endorse this update, we wished to provide further information about specific antibiotic treatments. The present update focuses on antibiotics with good distribution in bone and joint. It is important to monitor their dosage, which should be maximized according to PK/PD parameters. Dosages proposed in this update are high, with the optimized mode of administration for intravenous betalactams (continuous or intermittent infusion). We give tools for the best dosage adaptation to conditions such as obesity or renal insufficiency. In case of enterobacter infection, with an antibiogram result "susceptible for high dosage", we recommend the requesting of specialized advice from an ID physician. More often than not, it is possible to prescribe antibiotics via the oral route as soon as blood cultures are sterile and clinical have symptoms shown improvement. Duration of antibiotic treatment is 6 weeks for Staphylococcus aureus, and 4 weeks for the other bacteria (except for Neisseria: 7 days).

[Bacteriophages in complex treatment of septic diseases of the hand]

OBJECTIVE

To evaluate the effectiveness of bacteriophages in complex surgical treatment of septic diseases of the hand.

MATERIAL AND METHODS

We analyzed treatment outcomes in 111 patients with septic diseases of the hand (septic arthritis, tendovaginitis, phlegmon). Surgical treatment was finished by primary sutures and drainage. They were divided into two groups. Bacteriophages were used in the main group. Other components of treatment were identical. «Pyobacteriophage complex» was injected into drainage tubes during dressings. Effectiveness of treatment was evaluated considering elimination of septic process, bacterial flora and healing of surgical wound. In addition, we performed in vitro testing of microorganisms for sensitivity to Pyobacteriophage.

RESULTS

Staphylococcus and Streptococcus genus prevailed in hand infections. Pasteurella multocida has been isolated after pet bites. Growth of microflora in drainage tubes was observed in 16.7% and 21.1% of cases, respectively (p=0.02). Wound healing via primary intention was found in 83.6% and 71.4%, respectively (p=0.03). When testing in vitro, we observed lysis of cultures of Staphylococcus aureus in 83.6% of cases, Streptococcus pyogenes - in 33.3% of cases.

CONCLUSION

«Pyobacteriophage complex» was effective for septic diseases of the hand. However, its partial lytic activity against the most common pathogens makes it advisable to combine phages and antibiotic therapy. Systematic renewal of phages is important due to widespread resistance of bacteria.

Septic arthritis of the hand: From etiopathogenesis to surgical treatment

BACKGROUND

Septic arthritis of the hand, which is the second most common after damage of the knee joint, remains one of the leading causes of temporary disability. An inflammation can cause dysfunction of the joint, and in the most severe cases, the need for amputation of the finger may arise. The results of their treatment today, especially from a functional point of view, cannot be considered satisfactory. Urgent surgical treatment is extremely important in septic arthritis of the hand, as it helps to prevent cartilage destruction and the development of osteomyelitis.

AIM

To explore the features of the course of septic arthritis of the hand as well as approaches to surgical treatment and its results, depending on the nature of the damage to the articular structures.

METHODS

The results of the treatment of 170 patients with septic arthritis of the hand, which were treated in the period of 2020-2021, were analyzed. Inflammation of the interphalangeal and metacarpophalangeal joints (MCP) of fingers 1, 2, and 3 was more often noted in 147 (81.6%) joints. The most common cause of arthritis was a penetrating injury as a result of household trauma (101, 59.4%), animal bite (30, 17.6%), and clenched fist injury (15, 8.8%). Septic arthritis with contiguous osteomyelitis was observed in 98 (54.4%) cases. Surgical treatment was completed with drainage and irrigation of the joint. Early mobilization was used to restore function. In patients with osteomyelitis, it was aimed at the formation of neoarthrosis. Arthrodesis was not applied. Long-term results of treatment were assessed in 142 (83.5%) patients within 1 mo to 12 mo after discharge from the hospital [the median was 7 mo (IQR: 4-9)].

RESULTS

The most commonly isolated organism was Staphylococcus aureus (35.3%). The median treatment delay in patients without osteomyelitis was 5 d (IQR: 4-7); for septic arthritis with contiguous osteomyelitis, it was 14 d (IQR: 5-21). Radiography for osteomyelitis within 2 wk was uninformative: 41.2% of diagnoses. A single surgical treatment was required in 138 (81.2%) patients, two treatments in 22 (12.9%), and three or more in 10 (5.9%). Total elimination of the infection was achieved in 163 (95.9%) patients. The best functional results of treatment were noted in patients without osteomyelitis. After septic arthritis, Total Active Motion (TAM) for the MCP was 96.2% (IQR: 85.1-98.0), for the proximal interphalangeal joint (PIP) 82.4% (IQR: 54.5-98.5), and for the distal interphalangeal joint (DIP) 69.4% (IQR: 65.4-74.1). In cases with osteomyelitis, it was possible to achieve the formation of neoarthrosis with TAM for MCP-64.2% (IQR: 45.3-90.1), for PIP-62.5% (IQR: 41.8-68.9), and for DIP-59.4% (IQR: 50-62.1). Additionally, the severity of pain during movements did not exceed 1 point.

CONCLUSION

The delay in treatment of patients with septic arthritis of the hand was accompanied by a high incidence of osteomyelitis, especially in the presence of diabetes mellitus. Urgent surgical treatment, along with continued irrigation of the joint and antibiotic therapy, made it possible to eliminate the infection, and early rehabilitation restored the range of motion. The best results were noted in patients without osteomyelitis. With the development of osteomyelitis, a complex of early rehabilitation measures also made it possible to partially restore the range of motion due to the formation of neoarthrosis, without resorting to arthrodesis.

Septic arthritis of the hand: Current issues of etiology, pathogenesis, diagnosis, treatment

Septic arthritis of the hand is a serious disease that often results in dysfunction of the joint or even the need to perform amputation of the finger. They rank second in the frequency of occurrence after lesions of the knee joint. Many points concerning the etiology, the timing of the development of cartilage destruction and the development of osteomyelitis, approaches to surgical treatment, the duration of antibiotic therapy, and the start of rehabilitation measures remain the subject of numerous discussions. Based on a search in the PubMed, Web of Science and Google Scholar databases down to 1990-2021, publications on septic arthritis of the hand were found and analyzed. The following inclusion criteria were used in our review: (1) Septic arthritis of the hand; (2) Published in a peer review journal; (3) Written in English; and (4) Full text version available. Studies were excluded if they met any of the following criteria: (1) Letters; (2) Articles published in abstract form only; and (3) Cadaveric studies. Septic arthritis of the hand was characterized by the most frequent damage to the joints of the index and middle fingers (> 50% of cases). Up to 90% of cases, the infection enters the joint as a result of penetrating trauma, animal bites, etc. Staphylococcus aureus became the most frequently isolated microorganism (30%-55%), and its polyantibiotic-resistant form Methicillin-resistant Staphylococcus aureus was found, according to various sources, from 0% to 73% among all isolated Staphylococcus aureus. In arthritis, Pasteurella multocida (6%-11%) is often isolated as a result of animal bites. Articular cartilage destruction in the experiment developed within 24-48 h after infection. In clinical studies, the development of osteomyelitis was noted when treatment was delayed by more than 10 d. X-ray data during the first two weeks were uninformative. Priority of surgical treatment of septic arthritis. Drainage and surgical treatment, and with the development of osteomyelitis, the implementation of arthrodesis. Antibacterial therapy for 2-4 wk and early start of rehabilitation measures. Timely surgical treatment in combination with antibiotic therapy and rehabilitation makes it possible to obtain a positive result in the treatment of septic arthritis of the hand.

Clinical Overview of Arthritis with a Focus on Management Options and Preventive Lifestyle Measures for Its Control

ABSTRACT:

Arthritis is the spectrum of conditions that cause swelling and tenderness of one or more body joints with key symptoms of joint pain and stiffness. Its progression is closely tied to age. Although there are a number of arthritis types, such as, ankylosing, gout, joint infections, juvenile idiopathic, reactive and septic; the two most common types are osteoarthritis and rheumatoid arthritis. Osteoarthritis causes the articulating smooth cartilage that covers the ends of bones, where they form a joint, to breakdown. Rheumatoid arthritis is a disease in which the immune system attacks joints, beginning with the cartilaginous lining of the joints. The latter is considered a systemic disease, i.e. affecting many parts of the body, but the respiratory system is involved in 10 to 20 % of all mortality. Osteoarthritis is one of the leading causes of disability globally. Several preventive measures to control arthritis have been suggested, such as the use of analgesics, non-steroid anti-inflammatory drugs, moderate to vigorous physical activity and exercise, reducing sedentary hours, getting adequate sleep and maintaining a healthy body weight. Foods including, a Mediterranean diet rich in fruits and vegetables, fish oil, medicinal plants and microbiota are vital protective methods. The intake of vitamins such as A and C, minerals e.g., selenium and zinc; poly unsaturated and n-3 fatty acids is also a significant preventive measures.

Septic arthritis of the fingers: is short-term oral antibiotic therapy appropriate?

The management of septic arthritis of the hand is poorly described and there is no consensus. It is based on how septic arthritis of the large joints is managed, despite certain specificities related to the hand, typically involving inpatient management and intravenous antibiotic therapy. The primary objective of this work was to evaluate our postoperative protocol for the management of septic arthritis of the hand with short-term antibiotic therapy. The secondary objective was to determine the risk factors for treatment failure. We conducted a retrospective, descriptive, single-center study and analyzed the medical records of patients managed for septic arthritis of the fingers over a 1-year period from January 2018 to December 2018. We collected patient demographics and all pre-, intra-, and postoperative data. A total of 128 patients were included. The median age was 52.4 years (41-66). An exogenous source of contamination was reported in 98% of cases (animal bite, plant thorn, wound, cyst trituration, etc.). The most frequently isolated microorganism was Staphylococcus aureus (45%), followed by Streptococcus spp. (22%) and Pasteurella spp. (18%). The vast majority of patients (79%) were treated with oral amoxicillin/clavulanic acid. This treatment was continued in 91% of patients after microbiological results were obtained for a median treatment duration of 8 days (7-15). Nine percent of patients failed treatment. The risk factors identified were crush wounds (p = 0.04), initial radiological abnormalities (chondrolysis and/or osteolysis) (p = 0.016) and infection with Pasteurella spp. (p = 0.015). Our study suggests that simplified antibiotic therapy is feasible for the management of septic arthritis of the hand with short duration, broad spectrum oral antibiotics in the absence of identified risk factors.

Primarily treated patients versus referred patients in the treatment of native septic arthritis of digits: a retrospective comparative study

BACKGROUND

Septic arthritis of digits needs urgent treatment. When treatments delayed or insufficient, patients may be referred to the upper-level hospital due to uncontrolled infection. We reviewed the treatment history of referred patients and compared the microorganisms and the clinical course of both primary and referred patients as relevant studies are rare.

METHODS

In this retrospective review of consecutive case series, 45 patients (primary, n = 11; referred, n = 34) were treated with multiple irrigation and debridement. Cefazolin was used as empiric antibiotics, then changed according to microbiologic study. Previously used antibiotics, treatment delay, surgical history of the referred patients were reviewed. Identified microorganisms, required surgical intervention, hospital stay, radiologic outcome, functional outcomes were compared between both groups.

RESULTS

In the referred patients, methicillin-resistant Staphylococcus aureus (MRSA) was commonly found and cefazolin was susceptible in only 15% of the cases. Longer hospital stay, prolonged antibiotic therapy, more surgical intervention including flap surgery was required to treat the referred patients. Postoperative pain was not severe in daily activities, but the final range of motion was significantly less in the referred patients compared to the primary patients.

CONCLUSIONS

This study suggests that in the treatment of uncontrolled septic arthritis of the digits, antibiotic agents covering MRSA may shorten the duration of antibiotic therapy in areas of high MRSA incidence. Besides, more number of I & D including flap surgery may be required for the referred patients compared with the primary patients. These findings can help the surgeon in setting up a treatment plan or in counseling of referred patients with uncontrolled septic arthritis of the digits.

Bone and joint infections of the hand

BACKGROUND

Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand.

OBJECTIVES

To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence.

SOURCES

We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients.

CONTENT

Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%.

IMPLICATIONS

Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.

Hand Infections

Hand infections can lead to debilitating and permanent disability, particularly if they are not treated promptly or properly. The unique anatomy of the hand, with its numerous enclosed and confined spaces, warrants special considerations. For instance, infections in deep spaces of the hand may require surgical drainage despite an appropriate course of antimicrobial treatment. Thorough history and examination are crucial in guiding further investigations and management, particularly because there are numerous mimickers of hand infections, such as gout and pseudogout.

Two weeks versus four weeks of antibiotic therapy after surgical drainage for native joint bacterial arthritis: a prospective, randomised, non-inferiority trial

Objective

The optimal duration of postsurgical antibiotic therapy for adult native joint bacterial arthritis remains unknown.

Methods

We conducted a prospective, unblinded, randomised, non-inferiority study comparing either 2 or 4 weeks of antibiotic therapy after surgical drainage of native joint bacterial arthritis in adults. Excluded were implant-related infections, episodes without surgical lavage and episodes with a follow-up of less than 2 months.

Results

We enrolled 154 cases: 77 in the 4-week arm and 77 in the 2-week arm. Median length of intravenous antibiotic treatment was 1 and 2 days, respectively. The median number of surgical lavages was 1 in both arms. Recurrence of infection was noted in three patients (2%): 1 in the 2-week arm (99% cure rate) and 2 in the 4-week arm (97% cure rate). There was no difference in the number of adverse events or sequelae between the study arms. Of the overall 154 arthritis cases, 99 concerned the hand and wrist, for which an additional subgroup analysis was performed. In this per-protocol subanalysis, we noted three recurrences: one in the 2-week arm (97 % cure); two in the 4-week arm (96 % cure) and witnessed sequelae in 50% in the 2-week arm versus 55% in the 4-week arm, of which five (13%) and six (13%) needed further interventions.

Conclusions

After initial surgical lavage for septic arthritis, 2 weeks of targeted antibiotic therapy is not inferior to 4 weeks regarding cure rate, adverse events or sequelae and leads to a significantly shorter hospital stay, at least for hand and wrist arthritis.

Trial registration number

NCT03615781.

Epidemiology, Management, and Outcomes of Large and Small Native Joint Septic Arthritis in Adults

Background

Native joint septic arthritis (NJSA) is poorly studied. We describe the epidemiology, treatment, and outcomes of large joint NJSA (LNJSA) and small joint NJSA (SNJSA) in adults at Middlemore Hospital, Auckland, New Zealand.

Methods

This was a coding-based retrospective study of patients ≥16 years old admitted between 2009 and 2014. Prosthetic joint infections were excluded.

Results

Five hundred forty-three NJSA episodes were included (302 LNJSA, 250 SNJSA). Only 40% had positive synovial fluid culture. Compared to SNJSA, LNJSA has higher incidence (13 vs 8/100 000 person-years [PY]), occurs in older, more comorbid patients, and is associated with greater rates of treatment failure (23% vs 12%) and mortality, despite longer antibiotic treatment. Total incidence is higher than previously reported (21/100 000 PY), with marked interethnic variation. Incidence rises with age (LNJSA only) and socioeconomic deprivation (LNJSA and SNJSA). Tobacco smokers and males are overrepresented. The most commonly involved joints were knee (21%) and hand interphalangeal (20%). Staphylococcus aureus was the most common pathogen (53%). Mean antibiotic duration was 25 days for SNJSA and 40 days for LNJSA, and the mean number of surgical procedures was 1.5 and 1.6, respectively. Treatment failure was independently associated with LNJSA, age, intra-articular nonarthroplasty prosthesis, and number of surgical procedures.

Conclusions

This is the largest contemporary series of adult NJSA. SNJSA has better outcomes than LNJSA and may be able to be safely treated with shorter antimicrobial courses. Incidence is high, with significant ethnic and socioeconomic variation. Microbiological NJSA case ascertainment underestimates case numbers as it frequently excludes SNJSA.

Characteristics and Outcome of Twenty-Nine Implant-Related Infections of the Hand and Fingers: Results from a Twelve-Year Observational Study

BACKGROUND

Implant-related infections in hand surgery are dreaded complications, potentially leading to loss of finger joint function or amputation. Knowledge about the clinical presentation and treatment concepts of these infections is limited. The aim of this study is to present a consecutive series of patients with implant-related infections of the finger joints and wrist.

PATIENTS AND METHODS

We identified 25 patients with 29 implant-related infections. Infections were categorized as osteosynthesis-related infections (ORIs) or arthroplasty-related infections (ARIs). Further categorization included early and late post-operative (four weeks or less or more than four weeks after implantation) and exogenous and hematogenous infection.

RESULTS

Compared with patients with ARIs (n = 11), those with ORIs (n = 14) were predominantly male (n = 11), were younger (mean 43 vs. 65 years, p = 0.0023), had few or no comorbidities, and had an exogenous source of infection. Patients with ARIs were predominantly female with rheumatoid arthritis (n = 8) and had a hematogenous pathogenesis. Infections occurred late in 22 (88%) patients. The most commonly isolated micro-organism was Staphylococcus aureus (n = 12; 48%). All ORIs were treated with implant removal and a median antimicrobial treatment duration of 39 days (interquartile range [IQR] 28-50 days). In the ARI group, the implant was removed in three patients and exchanged in three patients (one-stage exchange in one patient, two-stage exchange in two patients). In five individuals, debridement and implant retention was performed. The median antimicrobial treatment duration for ARIs was 42 days (IQR 30-75 days). The median follow-up time was 96 days (IQR 42-258 days) and infection was cured or presumably cured in 22 patients (88%).

CONCLUSION

Our series shows distinct host and clinical patterns in ORIs and ARIs, supporting this categorization. The infection prognosis in ORIs is excellent with implant removal and antimicrobial treatment. Treatment concepts in ARIs are often derived from algorithms for periprosthetic joint infections of larger joints and need to be further elucidated.