Early Debridement, antibiotics and implant retention (DAIR) in patients with suspected acute infection after hip or knee arthroplasty - safe, effective and without negative functional impact

Effects of Vancomycin/Tobramycin-Doped Ceramic Composite (Polyvinyl Alcohol Composite-Vancomycin/Tobramycin-Polymeric Dicalcium Phosphate Dihydrate) in a Rat Femur Model Implanted With Contaminated Porous Titanium Cylinders

BACKGROUND

Periprosthetic joint infection (PJI) remains common and problematic. We hypothesized that using a bioceramic that provided rapid release of the antibiotics (vancomycin [VAN] or VAN and tobramycin [VAN and TOB]) from a polyvinyl-alcohol-composite (PVA) combined with a delayed and sustained antibiotic release from polymeric-dicalcium-phosphate-dihydrate (PDCPD) ceramic would inhibit S. aureus-associated implant infections.

METHODS

A total of 50 male Sprague Dawley rats were randomly divided into 5 groups-I: negative control; II: bacteria only; III: bacteria + saline wash; IV: bacteria + PVA-VAN-PDCPD, and V: bacteria + PVA-VAN-TOB-PDCPD. A porous titanium (Ti) implant was press-fit into the rat knee. S. aureus-containing broth was added into the joint space creating a PJI. After 1 week, the joints from groups III to V were washed with saline and the fluid collected for bacterial quantification. This was followed by saline irrigation treatment (groups III to V) and application of the antibiotic-loaded PVA-PDCPD bioceramic (groups IV and V). On day 21, joint fluid was collected, and the implants harvested for bacterial quantification.

RESULTS

No bacteria were isolated from the negative control (group I). The positive control (group II) was positive on both days 7 and 21. Bacteria were still present on day 21 in the fluid and implant in group III. Groups (IV and V) showed a decrease in the bacterial burden in the fluid and implant on day 21. There were significant differences in bacteria levels in the collected wash fluid and on the implant at day 21 between the saline wash (group III) and treatment groups (IV and V).

CONCLUSIONS

In this animal model of acute periprosthetic infection, treatment with PVA-VAN-PDCPD and PVA-VAN/TOB-PDCPD reduced bacterial load in the infected joint and the infected Ti implant. Application of PVA-VAN-PDCPD and/or PVA-VAN/TOB-PDCPD after saline irrigation could be used as an addition to the treatment of PJI.

Debridement, Antibiotics, and Implant Retention in Unicompartmental Knee Arthroplasty Infection

BACKGROUND

This multicenter study sought to further investigate the method and outcome of debridement, antibiotics, and implant retention (DAIR) for the management of unicompartmental knee periprosthetic joint infection (PJI).

METHODS

This retrospective study was performed on 52 patients who underwent DAIR for PJI of a unicompartmental knee arthroplasty (UKA) across 4 academic medical centers, all performed by fellowship-trained arthroplasty surgeons. Patient demographics, American Society of Anesthesiologists score, infecting organism, operative data, antibiotic data, and success in infection control at 1 year were collected.

RESULTS

The average time from index surgery to diagnosis of PJI was 11.1 weeks (range, 1.4 to 48). There was no correlation between time of diagnosis and success at 1 year (R = 0.09, P = .46). There was an association between surgical synovectomy and the eradication of infection (R = 0.28, P = .04). Overall, there was an 80.8% (42 of 52) infection-controlled success rate at 1 year from the DAIR procedure. All DAIR failures went on to require another procedure, either 1-stage (2 of 10) or 2-stage (8 of 10) revision to total knee arthroplasty (TKA). Of the DAIR successes, 6 (14.3%) went on to require conversion to TKA for progression of arthritis within 5 years.

CONCLUSIONS

This study demonstrates that DAIR is a safe and moderately effective procedure in the setting of acute PJI of UKA across institutions, with a success rate consistent with DAIR for TKA. The data suggest that a wide exposure and thorough synovectomy be incorporated during the DAIR UKA to improve the likelihood of successful eradication of PJI at the 1-year mark.

LEVEL OF EVIDENCE

Level III.

Current Status and Perspectives of Diagnosis and Treatment of Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) is a catastrophic complication following joint replacement surgery, posing significant challenges to orthopedic surgeons. Due to the lack of a definitive diagnostic gold standard, timely treatment initiation is problematic, resulting in substantial economic burdens on patients and society. In this review, we thoroughly analyze the complexities of PJI and emphasize the importance of accurate diagnosis and effective treatment. The article specifically focuses on the advancements in diagnostic techniques, ranging from traditional pathogen culture to advanced molecular diagnostics, and discusses their role in enhancing diagnostic accuracy. Additionally, we review the latest surgical management strategies, including everything from debridement to revision surgeries. Our summary aims to provide practical information for the diagnosis and treatment of PJI and encourages further research to improve diagnostic accuracy and treatment outcomes.

Fellowship Training in Arthroplasty Improves Treatment Success of Debridement, Antibiotics, and Implant Retention for Periprosthetic Knee Infections

Background

Debridement, antibiotics, and implant retention (DAIR) is a well-accepted surgical strategy for periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). DAIR in TKA may be incorrectly thought of as a "simple" procedure not requiring formal specialized training in arthroplasty. Currently, there are no studies comparing the risk of treatment failure based on surgeon fellowship training.

Methods

A retrospective review was performed of consecutive patients who underwent DAIR for TKA PJI at our institution. Two cohorts were created based on whether DAIR was performed by an arthroplasty fellowship-trained (FT) surgeon or nonarthroplasty fellowship-trained (NoFT) surgeon. Primary outcome was treatment failure following DAIR at a minimum of 1 year postoperatively. Treatment failure was based on the Tier 1 International Consensus Meeting definition of infection control. Secondary outcomes were also recorded including death during the totality of PJI treatment.

Results

A total of 112 patients were identified (FT = 68, NoFT = 44). At a mean follow-up of 7.3 years [standard deviation = 3.9], 73 patients (59.8%) failed treatment. Fellowship training in arthroplasty significantly improved treatment success rates (FT, 35/68 [51.5%]; NoFT, 10/44 [22.7%]; odds ratio 2.5 [95% confidence interval 1.1 to 5.9; P = .002]). Survivorship also differed significantly between the cohorts; at timepoints of 1.5 months, 5 months, 30 months, and 180 months, survivorship of the FT cohort was 79.4%, 67.6%, 54.4%, and 50.7%, respectively, compared with a survivorship of 65.9%, 52.3%, 25%, and 22.7% in the NoFT cohort (P = .002).

Conclusions

TKA PJI treated with DAIR should not be considered a simple procedure. Improved treatment success may be associated with subspecialty fellowship training in arthroplasty.

Level of Evidence

IV.

Lower Rates of Reoperation Following Partial or Complete Revision Arthroplasty Compared to Debridement, Antibiotics, and Implant Retention for Early Postoperative and Acute Hematogenous Periprosthetic Hip Infection

BACKGROUND

This study aimed to: 1) compare treatment outcomes between debridement, antibiotics, and implant retention (DAIR) and partial or complete revision arthroplasty (RA) for early postoperative and acute hematogenous total hip arthroplasty periprosthetic joint infection (PJI) and 2) identify factors associated with treatment outcome.

METHODS

The study consisted of a retrospective cohort of patients who underwent surgery for PJI between 2004 and 2021. There were 76 patients (74.5%) who underwent DAIR and 26 patients (25.5%) who underwent RA. Treatment success was defined as treatment eradication at a minimum of a 2-year follow up. Bivariate regression analysis was used to assess the effect of different factors on treatment outcomes. Kaplan-Meier survivorship was performed to compare survivorship between cohorts.

RESULTS

At a mean follow-up of 8.2 years (range, 2.2 to 16.4), significantly more DAIR failed treatment (DAIR, 50 [65.8%]; 10 [38.5%]; P = .015). The 8-year Kaplan-Meier survivorship was 35.1% [95% confidence interval (CI), 24.3 to 45.9] for patients treated with DAIR and 61.5% [95% CI, 42.9 to 80.1] for those treated with RA (log rank = 0.039). Bivariate regression analysis showed performing a RA was associated with a higher likelihood of treatment success (odds ratio 4.499, 95% CI 1.600 to 12.647, P = .004), whereas a higher body mass index was associated with treatment failure (odds ratio 0.934, 95% CI 0.878 to 0.994, P = .032).

CONCLUSIONS

To reduce the rate of recalcitrant infection following early postoperative or acute hematogenous total hip arthroplasty PJI, RA may be of benefit over DAIR. This is especially relevant in the early postoperative period, when components can be readily exchanged.

The stability of Staphylococcal bacteriophages with commonly used prosthetic joint infection lavage solutions

The aim of this study was to assess the viability of four Staphylococcal bacteriophages when exposed to different concentrations of commonly used lavage solutions in the surgical treatment of prosthetic joint infections (PJI). Four tailed Staphylococcal bacteriophages and six different lavage solutions (chlorhexidine 4%, hydrogen peroxide 3%, acetic acid 3%, povidone iodine 10%, sodium hypochlorite 0.5%, and Vashe solution) at 100%, 1%, and 0.01% concentrations were used in this experiment. In addition, the temporal impact of exposing bacteriophages to these lavage solutions was also evaluated at 5-min exposures and 24-h exposures. The results show that the titers of the four bacteriophages were statistically significantly decreased for all lavage solutions (100% and 1%) at 5-min exposures and 24-h exposures. However, with 0.01% concentrations of the lavage solutions, only acetic acid caused a statistically significant decrease in bacteriophage titers compared to normal saline control. Our findings suggest that tailed Staphylococcal bacteriophages do not remain stable in high concentrations of the most commonly used lavage solutions. However, at very dilute concentrations the bacteriophages do remain viable. This has important clinical ramifications in that it shows when using bacteriophage therapy for PJI it is critical to thoroughly wash out any lavage solutions before the introduction of therapeutic bacteriophages especially when acetic acid is used.

Outcomes after débridement, antibiotics, and implant retention for prosthetic joint infection in shoulder arthroplasty

BACKGROUND

Patients who undergo total shoulder arthroplasty usually have excellent long-term outcomes. However, a subset of patients is diagnosed with a prosthetic joint infection (PJI) requiring revision procedures and prolonged recovery. The purpose of this study was to evaluate rates of recurrent shoulder PJI in patients undergoing débridement, antibiotics, and implant retention (DAIR), single-stage revision, and 2-stage revision. We also sought to compare outcomes and complications across procedures.

METHODS

Retrospective chart review was conducted for patients diagnosed with PJI after primary shoulder arthroplasty between January 2010 and August 2021. Patients were included if they underwent treatment with DAIR, single-stage revision, or 2-stage revision. Demographic information, surgical details, complications, laboratory data, postoperative antibiotic regimen, and infectious pathogen were collected. Postoperative patient-reported outcomes were collected: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation, Shoulder Activity Scale, and PROMIS Upper Extremity. Chi-square, t test, and 1-way analysis of variance were used as appropriate to evaluate each factor.

RESULTS

Sixty-five patients were included in the study, 26% treated with DAIR, 9% treated with single-stage revision, and 65% treated with 2-stage revision. There were no significant differences in patient comorbidities. Patients undergoing DAIR were diagnosed significantly earlier than those undergoing single- and 2-stage revision procedures (12.6 ± 22.9 months vs. 49.6 ± 48.4 vs. 25.0 ± 26.6, P = .010). Recurrent PJI was noted in 23.1% of patients: 29.4% of DAIR patients, no single-stage patients, and 23.8% of 2-stage patients (P = .330). Patients undergoing 2-stage revision with treatment failure had a significantly higher Elixhauser Comorbidity Index (0.2 ± 3.7 vs. 3.7 ± 3.9, P = .027). There was no significant difference in patient-reported outcomes across groups.

CONCLUSION

Patients undergoing treatment of shoulder PJI with DAIR did not have an increased rate of reinfection compared with single-stage and 2-stage revision procedures. Patients treated with DAIR were diagnosed with PJI significantly earlier than those undergoing single-stage and 2-stage revision procedures. There was no difference in complication rates between groups. This information adds to the body of work detailing outcomes after DAIR for shoulder PJI and provides encouraging data for use in this patient population. Future studies with a larger sample size may be conducted to further investigate specific pathogens, infection timelines, and antibiotic regimens that reduce the risk of treatment failure.

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review

PURPOSE

Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported.

RESULTS

The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%).

CONCLUSION

Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.

Outcomes After Successful Debridement, Antibiotic, and Implant Retention Therapy for Periprosthetic Joint Infection in Total Knee Arthroplasty

BACKGROUND

Controversy surrounds debridement, antibiotic and implant retention (DAIR) for treatment of acute periprosthetic joint infection (PJI). Data regarding DAIR's rate of infection resolution is variable with little investigation of functional outcomes.

METHODS

We identified 191 DAIR cases at a single institution from 2008 to 2020. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient Reported Outcome Measurement Information System-10 (PROMIS) scores were collected. Patient Reported Outcome Scores were obtained from 60 cases. Median follow-up (IQR) was 4.5 (2.1 to 7.6) versus 3.0 (1.2 to 5.3) years for the control group. Mean scores were compared to a cohort of uncomplicated total knee arthroplasties matched by age, body mass index, and sex using generalized linear models adjusted for follow-up duration. Kaplan-Meier survivorship curves for PJI were constructed.

RESULTS

Mean Patient Reported Outcome Scores for the DAIR cohort were 57.2 ± 19.7 for KOOS-JR, 41.6 ± 7.1 for PROMIS physical health (PH), and 46.6 ± 8.7 for PROMIS mental health (MH). Mean control group values were 65.8 ± 21.0 for KOOS-JR, 44.6 ± 8.4 for PROMIS PH, and 49.2 ± 9.2 for PROMIS MH. No difference was observed in KOOS-JR (P = .83) or PROMIS MH (P = .11). PROMIS PH was lower in the DAIR cohort compared to the control group (P = .048). Median follow-up (years) for all 191 cases was 5.9 (range, 0.5 to 13.1). Survivorship (years) without subsequent operation for infection was 84% at 1, 82% at 2, and 79% at 5.

CONCLUSION

Knee and MH outcomes in successful DAIR procedures were similar to uncomplicated total knee arthroplasty. DAIR's success rate was 79% in treating acute PJI at 5 years.

LEVEL OF EVIDENCE

Level III.

What Is the Most Effective Treatment for Periprosthetic Joint Infection After Total Joint Arthroplasty in Patients with Rheumatoid Arthritis?: A Systematic Review

BACKGROUND

Rheumatoid arthritis (RA) is a risk factor for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of this study was to perform a systematic review comparing the failure rates of debridement, antibiotics, and implant retention (DAIR), one-stage exchange arthroplasty/revision (OSR), and 2-stage exchange arthroplasty/revision (TSR) for RA patients with PJI and identify risk factors in the RA population associated with increased treatment failure rate.

METHODS

PubMed, Ovid MEDLINE, and Ovid Embase databases were screened with the terms "rheumatoid arthritis," "total joint arthroplasty," "prosthetic joint infection," and "treatment for PJI" on August 29, 2021. Four hundred ninety-one studies were screened, of which 86 were evaluated. The primary outcome evaluated was failure of surgical treatment for PJI.

RESULTS

Ten retrospective cohort studies were included after full-text screening, yielding 401 patients with RA. Additional demographic and PJI management data were obtained for 149 patients. Patients with RA who underwent TSR demonstrated a lower failure rate (26.8%) than both DAIR (60.1%) and OSR (39.2%) (χ2 = 37.463, p < 0.00001). Patients with RA who underwent DAIR had a 2.27 (95% CI, 1.66-3.10) times higher risk of experiencing treatment failure than those who underwent TSR. Among risk factors, there was a significant difference in the C-reactive protein of patients who did vs. did not experience treatment failure (p = 0.02).

CONCLUSION

TSR has a higher rate of success in the management of PJI patients with RA compared with DAIR and OSR. The complete removal of the infected prosthesis and delayed reimplantation may lower the treatment failure rate.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Prosthetic Joint Infection on Work Status and Quality of Life: A Multicenter, International Study

BACKGROUND

Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up.

METHODS

Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria.

RESULTS

Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA.

CONCLUSIONS

A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets.

LEVEL OF EVIDENCE

Case series (IV).

A Review of Surgical Irrigation Solutions for Infection Prevention in Orthopaedic Surgery

» Intraoperative surgical irrigation is a common practice in orthopaedic procedures, although there is no universally established standard of care due to a lack of concrete data supporting an optimal irrigation agent.» Isotonic normal saline has long been considered a safe and cost effective solution for wound irrigation as compared with other antibiotic and antiseptic irrigation solutions.» Currently, the only adjunct to saline that is formally supported by American Academy of Orthopaedic Surgeons, the Centers for Disease Control and Prevention, and World Health Organization is povidone-iodine.» Further in vivo clinical studies are needed to identify the ideal irrigation solution that carries low cytotoxic effects while also exerting optimal antimicrobial properties.

An In Vitro Study to Assess the Best Strategy for the Chemical Debridement of Periprosthetic Joint Infection

Irrigation and debridement using an irrigation solution is a fundamental step during the surgical treatment of both acute and chronic periprosthetic joint infection (PJI). However, there is no consensus on the optimal solution, nor is there sufficient evidence on the optimal irrigation time and combination of solutions. Therefore, it is necessary to determine which solution or combination of solutions is most efficacious against biofilm, as well as the optimal irrigation time. We conducted an experimental in vitro model by inoculating stainless steel discs with ATCC strains of methicillin-susceptible Staphylococcus aureus, methicillin-resistant S. aureus, Pseudomonas aeruginosa, and a clinical strain of Staphylococcus epidermidis. The discs were all irrigated with commonly used antiseptic solutions (10% and 3% povidone iodine, hydrogen peroxide, 3% acetic acid, and Bactisure™) for 1 min, 3 min, and 5 min and their combinations for 9 min (3 min each) vs. sterile saline as a positive control. We evaluated the reduction in biofilm based on colony-forming unit (cfu) counts and in combination assays, also based on cell viability and scanning electron microscopy. All antiseptics alone reduced more than 90% of cfu counts after 1 min of irrigation; the worst results were for hydrogen peroxide and 3% acetic acid. When solutions were sequentially combined, the best results were observed for all those starting with acetic acid, in terms of both reduction of log cfu/mL counts and viable cells. We consider that a combination of antiseptic solutions, particularly that comprising the sequence acetic acid + povidone iodine + hydrogen peroxide, would be the best option for chemical debridement during PJI surgery.

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort

PURPOSE

The primary aim of the present study is to report the late acute hematogenous (LAH) prosthetic joint infection (PJI) cure rate following Total knee arthroplasty (TKA) treated by means of debridement, antibiotics, and implant retention (DAIR) in a long-term follow-up. The secondary purpose is to report the functional outcomes at that follow-up and to compare them with a non-infected group.

MATERIAL AND METHODS

This study cohort consists of 2,498 TKA performed from September 2005 to April 2010 that had a minimum follow-up of 10 years. The diagnosis of PJI and classification into LAH was done in accordance with the Zimmerli criteria. The primary outcome was the failure rate, defined as death before the end of antibiotic treatment, a further surgical intervention for treatment of infection, life-long antibiotic suppressive treatment or chronic infection. The Knee Society Score (KSS) was used to evaluate clinical outcomes.

RESULTS

Ten patients were diagnosed with acute hematogenous PJI during the study period (0.4%). All of them were managed with DAIR, which was performed by a knee surgeon and/or PJI surgeon. The failure rate was 0% at the 8.5-year (SD, 2.4) follow-up mark. The KSS score was 82.1 vs. 84.1 (p n.s.) at final follow-up.

CONCLUSION

Although the literature suggests that TKA DAIR for LAH periprosthetic joint infection is associated with high rates of failure, the results presented here suggest a high cure rate with good functional outcomes.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Debridement, Antibiotics and Implant Retention: A Systematic Review of Strategies for Treatment of Early Infections after Revision Total Knee Arthroplasty

GOAL

The purpose of this review is to provide a systematic and comprehensive overview of the available literature on the treatment of an early prosthetic joint infection (PJI) after revision total knee arthroplasty (TKA) and provide treatment guidelines.

METHODS

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using the electronic databases of PubMed, Trip, Cochrane, Embase, LILACS and SciElo. After the inclusion of the relevant articles, we extracted the data and results to compose a treatment algorithm for early and acute PJI after revision TKA.

RESULTS

After applying the in- and exclusion criteria, seven articles were included in this systematic review focusing on debridement, antibiotics and implant retention (DAIR) for PJI following revision TKA, of which one was prospective and six were retrospective. All studies were qualified as level IV evidence.

CONCLUSIONS

The current literature suggests that DAIR is a valid treatment option for early infections after revision TKA with success rates of 50-70%. Repeat DAIR shows success rates of around 50%. Further research should be aimed at predicting successful (repeat/two-stage) DAIRs in larger study populations, antibiotic regimes and the cost effectiveness of a second DAIR after revision TKA.

1.5-Stage Versus 2-Stage Exchange Total Hip Arthroplasty for Chronic Periprosthetic Joint Infections: A Comparison of Survivorships, Reinfections, and Patient-Reported Outcomes

BACKGROUND

Management of periprosthetic joint infection after total hip arthroplasty (THA) has traditionally consisted of a 2-stage approach. However, 1.5-stage exchange has garnered recent interest. We compared 1.5-stage to 2-stage exchange recipients. Specifically, we assessed (1) infection-free survivorship and risk factors for reinfection; (2) 2-year surgical/medical outcomes (eg, reoperations, readmissions); (3) Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS-JR); and (4) radiographic outcomes (ie, progressive radiolucent lines, subsidences, and failures).

METHODS

We reviewed a consecutive series of 1.5-stage or planned 2-stage THAs. A total of 123 hips were included (1.5-stage: n = 54; 2-stage: n = 69) with mean clinical follow-up of 2.5 years (up to 8 years). Bivariate analyses assessed incidences of medical and surgical outcomes. Additionally, HOOS-JR scores and radiographs were evaluated.

RESULTS

The 1.5-stage exchange had 11% greater infection-free survivorship at final follow-up compared to 2 stages (94% versus 83%, P = .048). Morbid obesity was the only independent risk factor demonstrating increased reinfection among both cohorts. No differences in surgical/medical outcomes were observed between groups (P = .730). HOOS-JR scores improved markedly for both cohorts (1.5-stage difference = 44.3, 2-stage difference = 32.5; P < .001). A total of 82% of 1.5-stage patients did not demonstrate progressive femoral or acetabular radiolucencies, while 94% of 2-stage recipients did not have femoral radiolucencies and 90% did not have acetabular radiolucencies.

CONCLUSION

The 1.5-stage exchange appeared to be an acceptable treatment alternative for periprosthetic joint infections after THAs with noninferior infection eradication. Therefore, this procedure should be considered by joint surgeons for treatment of periprosthetic hip infections.

Peri-Prosthetic Joint Infection in Patients Prescribed Suppressive Antibiotic Therapy Undergoing Primary Total Joint Arthroplasty: A 1:4 Case Control Matched Study

Background: Oral suppressive antibiotic therapy (SAT) has emerged as a potential means to increase rates of infection-free survival in many complex peri-prosthetic joint infection (PJI) cases after total joint arthroplasty (TJA). The purpose of the present study is to evaluate the risk of PJI of a new primary TJA in patients on oral SAT. Patients and Methods: A retrospective matched cohort study from five hospitals in a 20-year period within a large hospital network was performed. Inclusion criteria consisted of patients over age 18 undergoing primary TJA, with any order for oral long-term (>6 months duration) SAT, and minimum of one-year clinical follow-up. Patients were matched 1:4 on age, gender, body mass index (BMI), hip or knee surgery, diabetes mellitus, smoking status, and indication for primary TJA. Student t-test, Fisher exact, and χ² tests were utilized for group comparisons. Our study was powered to detect a 10.5% increase in PJI incidence compared with a 1% baseline rate of PJI. Results: We identified 45 TJA in 33 patients receiving SAT, which were matched to 180 control cases. There was no difference in the rate of development of PJI at any time point within follow-up between the SAT cohort and control group (2.22% vs. 1.11%; p = 0.561). Conclusions: We found a 2.22% rate of PJI in a cohort of patients receiving SAT identified over a 20-year period. As the clinical scenario of primary TJA while on SAT is rare but likely to become more prevalent, future large-scale studies can be performed to better clarify rates and risk of PJI in this population.

Preoperative and postoperative risk factors for periprosthetic joint infection in primary total hip arthroplasty: A 1-year experience

BACKGROUND

Periprosthetic joint infection (PJI) in primary total hip replacement (THR) is one of the most important threats in orthopedic surgery, so one important surgeon’s target is to avoid or early diagnose a PJI. Although the incidence of PJI is very low (0.69%) in our department, with an average follow-up of 595 d, this infection poses a serious threat due to the difficulties of treatment and the lower functional outcomes after healing.

AIM

To study the incidence of PJI in all operations occurring in the year 2016 in our department to look for predictive signs of potential infection.

METHODS

We counted 583 THR for 578 patients and observed only 4 cases of infection (0.69%) with a mean follow-up of 596 d (min 30, max 1451). We reviewed all medical records to collect the data: duration and time of the surgery, presence, type and duration of the antibiotic therapy, preoperative diagnosis, blood values before and after surgery, transfusions, presence of preoperative drugs (in particularly anticoagulants and antiaggregant, corticosteroids and immunosuppressants), presence of some comorbidities (high body mass index, blood hypertension, chronic obstructive pulmonary disease, cardiac ischemia, diabetes, rheumatological conditions, previous local infections).

RESULTS

No preoperative, intraoperative, or postoperative analysis showed a higher incidence of PJI. We did not find any class with evident major odds of PJI. In our study, we did not find any border value to predict PJI and all patients had similar values in both groups (non-PJI and PJI). Only some categories, such as female patients, showed more frequency of PJI, but this difference related to sex was not statistically significant.

CONCLUSION

We did not find any category with a higher risk of PJI in THR, probably due to the lack of few cases of infection.

Risk factors for recurrence of periprosthetic joint infection following operative management: a cohort study with average 5-year follow-up

Background

Periprosthetic joint infections (PJIs) remain challenging to eradicate even after surgical management, which in most cases involves either debridement, antibiotics and implant retention (DAIR) or single- or two-staged revision. The purpose of this study is to determine predictors of PJI recurrence after operative management for PJI, and to determine differences in recurrence-free survival between DAIR and staged revision.

Methods

This is a retrospective analysis of prospectively collected data of revision hip and knee arthroplasty surgeries due to PJI between 2011 and 2018 at an academic hospital. Any patient undergoing revision surgery for PJI was included except if the index surgery information was unknown. The primary outcome was confirmed PJI recurrence. Multivariable logistic regression analysis was utilized to determine the relationship between the predictor variables and outcome variable. Log rank testing was used to compare recurrence-free survival between DAIR and staged revision.

Results

A total of 89 patients (91 joints) underwent revision surgery due to PJI. Younger age and presence of a sinus tract were statistically significant for risk of PJI recurrence. A multivariable logistic regression model including both variables was significant for predicting recurrence of PJI (χ2=10.2, P=0.006). Survival was not significantly different between patients who underwent DAIR versus a staged revision.

Conclusions

Younger patients and those with a chronic sinus tract are at significantly higher risk of recurrent PJI. This study also demonstrated that PJI can be successfully managed in the majority of cases with DAIR or staged revision.

The role of antibiotic calcium sulfate beads in acute periprosthetic knee infection: a retrospective cohort study

Background

The study aimed to compare debridement, antibiotics, and implant retention (DAIR) vs. debridement antibiotic bead and retention of the implant (DABRI) in terms of infection-free success rate and treatment cost for acute periprosthetic joint infections after total knee arthroplasty (TKA).

Method

Between 2017 and 2020, 32 patients with acute periprosthetic joint infection who were treated by total knee arthroplasty were retrospectively reviewed. The patients were divided into a DAIR group (n=15) and a DABRI group (n=17). During the DABRI, additional calcium ulphate antibiotic beads were used. Patient age, the Musculoskeletal Infection Society score, microorganisms involved, and success rate were assessed.

Results

The mean age of DAIR group (n=15) was 69 years, with 7 being male, and 8 female. The mean follow-up period lasted 30 months. The success rate was 80% (12/15). The mean age of DABRI group (n=17) was 64 years, with 10 patients being male and 7 female. The mean follow-up period was 16 months. The success rate was 88% (15/17). There were no significant differences in patient age (P>0.05), the Musculoskeletal Infection Society score (P>0.05), and success rate (P>0.05). A significant difference was found in the follow-up period between the two groups (P<0.05).

Conclusion

Both DAIR and DABRI could be used to treat acute periprosthetic joint infections and the outcomes and treatment costs of the two procedures were comparable. Additional use of calcium sulfate beads was safe, but might not improve the treatment result. Randomized controlled studies are warranted for the routine use.

A review of current practices in periprosthetic joint infection debridement and revision arthroplasty

BACKGROUND

Periprosthetic joint infection remains a significant challenge for arthroplasty surgeons globally. Over the last few decades, there has been much advancement in terms of treatment and diagnosis, however, the fight rages on. As management of periprosthetic joint infections continues to evolve, it is critical to reflect back on current debridement practices to establish common ground as well as identify areas for future research and improvement. BODY: In order to understand the debridement techniques of periprosthetic joint infections, one must also understand how to diagnose a periprosthetic joint infection. Multiple definitions have been elucidated over the years with no single consensus established but rather sets of criteria. Once a diagnosis has been established the decision of debridement method becomes whether to proceed with single vs two-stage revision based on the probability of infection as well as individual patient factors. After much study, two-stage revision has emerged as the gold standard in the management of periprosthetic infections but single-stage remains prominent with further and further research.

CONCLUSION

Despite decades of data, there is no single treatment algorithm for periprosthetic joint infections and subsequent debridement technique. Our review touches on the goals of debridement while providing a perspective as to diagnosis and the particulars of how intraoperative factors such as intraarticular irrigation can play pivotal roles in infection eradication. By providing a perspective on current debridement practices, we hope to encourage future study and debate on how to address periprosthetic joint infections best.

Higher 1-year risk of implant removal for culture-positive than for culture-negative DAIR patients following 359 primary hip or knee arthroplasties

Background and purpose: To date, the value of culture results after debridement, antibiotics, and implant retention (DAIR) for early (suspected) prosthetic joint infection (PJI) as risk indicators in terms of prosthesis retention is not clear. At the 1-year follow-up, the relative risk of prosthesis removal was determined for culture-positive and culture-negative DAIR patients after primary total hip or knee arthroplasty. The secondary aim of this work was to explore differences in patient characteristics, infection characteristics, and outcomes between these two groups. Methods: A retrospective regional registry study was performed in a group of 359 patients (positive cultures: n=299; negative cultures: n=60) undergoing DAIR for high suspicion of early PJI in the period from 2014 to 2019. Differences in patient characteristics, the number of deceased patients, and the number of subsequent DAIR treatments between the culture-positive and culture-negative DAIR groups were analysed using independent t tests, Mann–Whitney U tests, Pearson's chi-square tests, and Fisher's exact tests. Results: The overall implant survival rate following DAIR was 89 %. The relative risk of prosthesis removal was 7.4 times higher (95 % confidence interval (CI) 1.0–53.1) in the culture-positive DAIR group (37 of 299, 12.4 %) compared with the culture-negative DAIR group (1 of 60, 1.7 %). The culture-positive group had a higher body mass index (p=0.034), a rate of wound leakage of >10 d (p=0.016), and more subsequent DAIR treatments (p=0.006). Interpretation: As implant survival results after DAIR are favourable, the threshold to perform a DAIR procedure for early (suspected) PJI should be low in order to retain the prosthesis. A DAIR procedure in the case of negative cultures does not seem to have unfavourable results in terms of prosthesis retention.

Outcomes of Concurrent Endocarditis and Periprosthetic Joint Infection: A Retrospective Case Series of 16 Patients

Introduction

Concurrent diagnosis of periprosthetic joint infection (PJI) of total hip arthroplasty (THA) or total knee arthroplasty (TKA) with infectious endocarditis is a devastating clinical scenario infrequently documented in the literature. To date, no studies have fully described the orthopedic and infectious outcomes of patients with these concurrent diagnoses. The purpose of this study was to conduct a case series of patients with these diagnoses and document the orthopedic and infectious outcomes so that surgeons may effectively counsel patients regarding the gravity of the condition and the expected course of treatment.

Methods

This study is a retrospective case series using patient data from five hospitals within an academic healthcare system in the northeastern United States. Cases of concurrent endocarditis and THA or TKA PJI with a minimum of one-year follow-up were identified from January 2000 to January 2021. Basic statistics such as means, standard deviations, and percentages were used to identify trends within our series. Kaplan-Meier survivorship curves with log-rank tests were performed to determine if there were any differences in two-year mortality and joint survival (defined as needing explant) between patients who had cardiac surgery prior to surgical management for their PJI and those who had surgical management for PJI prior to cardiac surgery.

Results

A total of 18 joints in 16 patients with endocarditis and concurrent TKA or THA PJI were identified. All PJIs were managed surgically, with 14/18 (77.77%) of joint infections initially being managed by debridement, antibiotics, and implant retention (DAIR) and 4/18 (22.22%) of joint infections initially being managed by explant. Within the first six months of PJI diagnosis, 25% (4/16) of patients died of complications related to their infection, and one additional patient died of bacteremia just over a year after the initial PJI diagnosis. Of the 18 PJIs, 72.23% (13/18) had treatment failure, defined as any outcome equal to or worse than requiring chronic suppressive antibiotics for the infection. Due to low statistical power, we were not able to identify any differences in two-year mortality from PJI diagnosis (p=0.311) or joint survival (in terms of requiring explant) (p=0.420) depending on whether cardiac surgery or DAIR was performed first.

Conclusions

Concurrent infectious endocarditis and prosthetic joint infection is associated with high morbidity and mortality. Patients with these concurrent infections should be counseled that not only the associated mortality rate is high, but also the surgical treatment of their PJI has a high rate of treatment failure, including an explant following an initial DAIR, an explant with retained spacer, or a requirement of lifelong antibiotic suppression.

Debridement, antibiotics, and implant retention after revision arthroplasty : antibiotic mismatch, timing, and repeated DAIR associated with poor outcome

AIMS

Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years.

METHODS

This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed.

RESULTS

The overall success rate of DAIR, with respect to the retention of components and the cure of infection, was 68% after two years. DAIR performed with an interval of > 30 days after the index revision procedure (odds ratio (OR) 0.24 (95% confidence interval (CI) 0.08 to 0.72); p = 0.008), a repeated DAIR within 90 days (OR 0.37 (95% CI 0.14 to 0.97); p = 0.040), and the use of an immunosuppressive agent (OR 0.13 (95% CI 0.02 to 0.67); p = 0.012) were associated with a significantly reduced success rate. In the culture-positive group, a mismatch between the antibiotic treatment and the susceptibility of the organism was associated with a significantly lower success rate (OR 0.13 (95% CI 0.03 to 0.62); p = 0.007).

CONCLUSION

DAIR is an acceptable form of surgical treatment for patients with a suspected early PJI after revision arthroplasty of the hip or knee. DAIRs performed after a prolonged interval, multiple DAIRs, and antibiotic mismatches were significantly associated with an increased risk of failure. Optimization of the host immune response and the prevention of antibiotic mismatch are modifiable factors that may improve the outcome. The high rate of mismatches was an important finding, underlining the need for a review of the local microbiological data, which might improve the outcome. Cite this article: Bone Joint J 2022;104-B(4):464-471.

Do Antibiotic-Loaded Calcium Sulfate Beads Improve Outcomes After Debridement, Antibiotics, and Implant Retention? A Matched Cohort Study

Background

Dissolvable antibiotic-loaded calcium sulfate beads are used as an intraoperative adjunct during debridement with antibiotics and implant retention (DAIR) for periprosthetic joint infections (PJI) to reduce the historically higher failure rates than one- or two-stage exchange. This study evaluated clinical outcomes after DAIRs performed with and without these antibiotic beads. The primary outcome was post-DAIR failure secondary to recurrent PJI at 2 years. The secondary outcome was early failure secondary to recurrent PJI within 90 days.

Material and methods

DAIRs performed for acute or acute hematogenous PJI at a single institution were retrospectively identified between 2013 and 2018. All DAIRs with adjunctive antibiotic beads (cases) were then exactly matched to a cohort of DAIRs without beads (controls) based on Charlson Comorbidity Index. The McNemar’s test and Wilcoxon signed-rank test were used to evaluate differences in outcomes and patient characteristics.

Results

Twenty DAIR cases (with antibiotic beads) were matched with 20 DAIR controls. There was no difference in age, sex, body mass index, joint, erythrocyte sedimentation rate, C-reactive protein, microbiology profile, antibiotic-resistance profile, or intraoperative lavage adjuncts between groups. There were no statistically significant differences between cases and controls for either overall infection-related failure at 2 years (P = .21) or early infection-related failure at 90 days (P = 1.00).

Conclusion

Adjunctive dissolvable antibiotic-loaded calcium sulfate beads did not reduce the incidence of recurrent PJIs at 2 years or 90 days postoperatively after DAIR. Given the added cost of these antibiotic dissolvable beads without clinical benefits, we cannot recommend their use as an adjunct treatment during DAIRs.

An Insight Into Lyme Prosthetic Joint Infection in Knee Arthroplasty: A Literature Review

Lyme prosthetic joint infection (PJI) is a rare event, but it is imperative to include Lyme disease as a possible cause of PJI in a Lyme-endemic region. The purpose of this article was to review the reported cases of Lyme PJIs in knee arthroplasty and to initiate the development of a treatment strategy. We found five cases of Lyme PJI in the literature. All patients lived in the northeastern region of the United States. Four patients were successfully treated with surgical intervention and postoperative antibiotics. One patient was successfully treated with intravenous and oral antibiotics for 6 weeks, without surgical intervention. Synovial fluid Lyme polymerase chain reaction and serological tests were positive in all patients. On follow-up visits, after completion of their treatment, all patients were asymptomatic with a painless functional knee. We recommend considering Lyme disease as a cause of culture-negative PJIs in endemic regions. Additional research is needed to clearly define a treatment algorithm. Based on our literature review, we cannot recommend a single best treatment modality for the treatment of Lyme PJI. However, early irrigation and débridement with administration of postoperative antibiotics may improve early clinical outcomes.

Multidisciplinary Approach to Multiple Multiresistant Agent Infection of Instrumented Spine Surgery: A Case Report

CASE

We report the case of a patient with consecutive infections with several multidrug-resistant agents-including carbapenem-resistant strains of Klebsiella pneumoniae among others-from a surgical wound infection after lumbar spine fusion, only successfully treated after the resort to novel antibiotics (ceftazidime-avibactam) in combination therapy.

CONCLUSIONS

Multidrug resistance has become a major challenge in today's medicine. Care should be taken to avoid their emergence, but when present, a multidisciplinary approach is mandatory to ensure clinically up-to-date treatment choices. Multimodal antibiotic schemes tend to show the most promising results, with which successful infection resolution can still be achieved.

Local antibiotic treatment with calcium sulfate as carrier material improves the outcome of debridement, antibiotics, and implant retention procedures for periprosthetic joint infections after hip arthroplasty – a retrospective study

Abstract. Purpose: Debridement, antibiotics, and implant retention (DAIR) is an established treatment modality in periprosthetic joint infections (PJIs), but success rates vary. This study compared the success of DAIR for PJIs after a total hip arthroplasty (THA), with or without local antibiotic delivery with CaSO4 as the carrier material. Methods: A retrospective review of DAIR for PJIs after THA performed between 2010 and 2018, including 41 patients is conducted. A total of 27 patients were treated by DAIR with local antibiotics with CaSO4 as the carrier material, and 14 patients were treated by a standard DAIR. The endpoints were treatment failure, defined as the need for a reoperation, either a second DAIR or a prosthesis removal or exchange due to persistent or recurrent infection, the initiation of a long-term suppressive antibiotic treatment, or death related to infection. Results: Considering any reoperation as an outcome, 11 of 14 cases treated without AB-CaSO4 (79 %) and 4 of the 27 cases treated with AB-CaSO4 failed (15 %). Considering revision as an outcome, 9 out of 14 cases treated without AB-CaSO4 (64 %) and 4 of the 27 cases treated with AB-CaSO4 (15 %) failed. A Kaplan–Meier survival analysis showed that local antibiotic delivery with CaSO4 as the carrier material led to a significantly longer infection-free survival, considering any surgical revision (p<0.0001; hazard ratio 8.9 (95 % CI 2.8–28.2)) or revision with component exchange (p=0.0015; hazard ratio 5.6 (95 % CI 1.7–18.2)) as the endpoint. Conclusion: The addition of local antibiotics with CaSO4 as the carrier material to DAIR for PJIs after THA significantly increases success rates, such as infection-free survival, any reoperation, and revision with component exchange in particular.

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

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

The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive.

PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics.

Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI.

Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described.

The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available.

Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054

Management strategies for prosthetic joint infection: long-term infection control rates, overall survival rates, functional and quality of life outcomes

DAIR (debridement, antibiotics, and implant retention), one-stage and two-stage revision surgery are the most common management strategies for prosthetic joint infection (PJI) management. Our knowledge concerning their efficacy is based on short to medium-term low-quality studies.

Most studies report infection recurrence rates or infection-free time intervals. However, long-term survival rates of the infection-free joints, functional and quality of life outcome data are of paramount importance.

DAIR, one-stage and two-stage revision strategies are not unique surgical techniques, presenting several variables. Infection control rates for the above strategies vary from 75% to 90%, but comparisons are difficult because different indications and patient selection criteria are used in each strategy.

Recent outcome data show that DAIR and one-stage revision in selected patients (based on host, bacteriological, soft tissue and type of infection criteria) may present improved functional and quality of life outcomes and reduced costs for health systems as compared to those of two-stage revision.

It is expected that health system administrators and providers will apply pressure on surgeons and departments towards the wider use of DAIR and one-stage revision strategies. It is the orthopaedic surgeon’s responsibility to conduct quality studies in order to fully clarify the indications and outcomes of the different revision strategies.

Cite this article: EFORT Open Rev 2021;6:727-734. DOI: 10.1302/2058-5241.6.210008

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

BACKGROUND

Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.

METHODS

A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.

RESULTS

Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.

CONCLUSION

Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.

Lyme Prosthetic Joint Infection in Total Knee Arthroplasty: A Case Report

CASE

An 81-year-old man from the northeastern United States presented with an acute Borrelia burgdorferi prosthetic joint infection (PJI) 15 years after undergoing a right total knee arthroplasty. He had no complications until his recent presentation. He was treated with irrigation and debridement with implant retention. Synovial fluid Lyme polymerase chain reaction and serological tests were positive. Postoperatively, he received oral doxycycline and at 6 weeks was asymptomatic. Four months later, he died of neuroborreliosis vasculitis, a complication of Lyme.

CONCLUSION

We recommend considering Lyme disease as a cause of culture-negative PJIs in endemic regions. Early surgical treatment may mitigate adverse outcomes of Lyme.

Antimicrobial TiO2 nanocomposite coatings for surfaces, dental and orthopaedic implants

Engineering of self-disinfecting surfaces to constrain the spread of SARS-CoV-2 is a challenging task for the scientific community because the human coronavirus spreads through respiratory droplets. Titania (TiO₂) nanocomposite antimicrobial coatings is one of the ideal remedies to disinfect pathogens (virus, bacteria, fungi) from common surfaces under light illumination. The photocatalytic disinfection efficiency of recent TiO₂ nanocomposite antimicrobial coatings for surfaces, dental and orthopaedic implants are emphasized in this review. Mostly, inorganic metals (e.g. copper (Cu), silver (Ag), manganese (Mn), etc), non-metals (e.g. fluorine (F), calcium (Ca), phosphorus (P)) and two-dimensional materials (e.g. MXenes, MOF, graphdiyne) were incorporated with TiO₂ to regulate the charge transfer mechanism, surface porosity, crystallinity, and the microbial disinfection efficiency. The antimicrobial activity of TiO₂ coatings was evaluated against the most crucial pathogenic microbes such as Escherichia coli, methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Bacillus subtilis, Legionella pneumophila, Staphylococcus aureus, Streptococcus mutans, T2 bacteriophage, H1N1, HCoV-NL63, vesicular stomatitis virus, bovine coronavirus. Silane functionalizing agents and polymers were used to coat the titanium (Ti) metal implants to introduce superhydrophobic features to avoid microbial adhesion. TiO₂ nanocomposite coatings in dental and orthopaedic metal implants disclosed exceptional bio-corrosion resistance, durability, biocompatibility, bone-formation capability, and long-term antimicrobial efficiency. Moreover, the commercial trend, techno-economics, challenges, and prospects of antimicrobial nanocomposite coatings are also discussed briefly.

Extensive skin necrosis after periprosthetic knee infection: a case that highlights the possibility of complications induced by low-molecular-weight heparin

We describe a case of a patient with atrial fibrillation, anticoagulated with dabigatran, that developed severe knee skin necrosis in the setting of an acute periprosthetic knee infection, after initiating low-molecular-weight heparin. A wide range of etiology hypotheses was discussed within a multidisciplinary team. The complex approach consisted of treating the underlying infection, multiple types of soft-tissue management, and stopping enoxaparin.

Economic burden of surgical management of surgical site infections following hip and knee replacements in Calgary, Alberta, Canada

OBJECTIVE

To evaluate the cost of 1-stage and 2-stage revisions, debridement, antibiotic and implant retention (DAIR) and DAIR with liner exchange for complex surgical site infections (SSIs) following hip and knee replacements.

DESIGN

Retrospective population-based economic analysis of patients undergoing intervention for SSIs between April 1, 2012 and March 31, 2019.

SETTING

The study was conducted in the Calgary zone of Alberta Health Services (AHS) in Canada.

PARTICIPANTS

Individuals >18 years with complex SSI following hip or knee replacement.

METHODS

Patients with complex SSIs were identified using the AHS infection prevention and control database. A combination of microcosting and gross costing methods were used to estimate 12- and 24-month costs following the initial hospital admission for arthroplasty. Subgroup, inverse Gaussian and γ regression analyses were used to evaluate the impact of age and comorbidities on cost.

RESULTS

In total, 142 patients with complex SSIs were identified, with a mean age of 66.8 years. Total direct medical costs in United States dollars of 2-stage revisions were ($100,992 (95% CI, 34,587-167,396) at 12 months. The 1-stage revision ($41,176; 95% CI, 23,361-58,991), DAIR with liner exchange ($41,267; 95% CI, 29,923-52,612) and DAIR ($46,605; 95% CI, 15,277-76,844) were associated with fewer costs at 12 months. Age >65 years and chronic complications of diabetes and hypertension were associated with increased costs in subgroup and regression analysis.

CONCLUSIONS

Medical costs are highest at 12 months and for 2-stage revisions in hip and knee complex SSI cases. Further work should explore surgical outcomes correlated with costs to enhance patient care.

Effect of a multidisciplinary team on the treatment of hip and knee prosthetic joint infections: a single-centre study of 154 infections

BACKGROUND

A multidisciplinary team responsible for the management plan of prosthetic joint infections (PJI) was founded in January 2008. The aim of this study was to investigate whether a decrease in the number of surgeries and length of stay (LOS) was seen in the management of PJI with the aid of the multidisciplinary team.

METHODS

This retrospective cohort study consisted of a total of 154 postoperative PJIs from three time periods: 21 PJIs from 2005 to 2007 (Group 1), 65 PJIs from 2011 to 2013 (Group 2), and 68 PJIs from 2015 to 2016 (Group 3). Successful outcome was classified as the retention of the original implant or revised implant and no infection-related death.

RESULTS

The median number of operations decreased from 2.0 operations (Group 1) to 1.0 operation (Group 3) (p = .023), and the median LOS was shortened from 49.0 days (Group 1) to 17.0 days (Group 3) (p = .000). The number of PJIs treated with two-stage exchange decreased from 52.4% (11/21, Group 1) to 16.2% (11/68, Group 3) (p = .004). Simultaneously, debridement, antibiotics, and implant retention (DAIR) as primary surgical treatment increased from 42.9% (9/21, Group 1) to 89.7% (61/68, Group 3) (p = .000). The successful outcome of DAIR improved from 55.6% (5/9, Group 1) to 85.2% (52/61, Group 3) (p = .077).

CONCLUSIONS

Treatment of PJI in a specialized centre with the aid of a multidisciplinary team lead to fewer surgeries and reduced LOS. Successful outcome of DAIR improved over time.

Pursuit of the ideal antiseptic irrigation solution in the management of periprosthetic joint infections

Irrigation and debridement in the treatment of periprosthetic joint infection (PJI) serve an integral role in the eradication of bacterial burden and subsequent re-infection rates. Identifying the optimal irrigation agent, however, remains challenging, as there is limited data on superiority. Direct comparison of different irrigation solutions remains difficult because of variability in treatment protocols. While basic science studies assist in the selection of irrigation fluids, in vitro results do not directly translate into clinical significance once implemented in vivo. Dilute povidone iodine, hydrogen peroxide, chlorhexidine gluconate, acetic acid, sodium hypochlorite, hypochlorous acid, and preformed combination solutions all have potential against a broad spectrum of PJI pathogens with their own unique advantages and disadvantages. Future clinical studies are needed to identify ideal irrigation solutions with optimal bactericidal properties and low cytotoxicity for PJI treatment.

Risk factors affect success rate of debridement, antibiotics and implant retention (DAIR) in periprosthetic joint infection

Background

Periprosthetic joint infection (PJI) is the most devastating complication of joint replacement that seriously affects the quality of life and causes a heavy burden to the families and society. Due to shorter hospital stays, lower costs, improved joint function and less morbidity, a process of debridement, antibiotics and implant retention (DAIR) is recommended as the preferred treatment for acute periprosthetic joint infection. However, the factors that impact the success rate of DAIR remain controversial. This article evaluates the influential factors of DAIR and provides insights for orthopaedics surgeons to make optimal decisions to improve the success rate of DAIR.

Conclusion

The poor general condition of patients, high preoperative C-reactive protein (CRP) level, repeated joint surgeries, and Methicillin-resistant Staphylococcus aureus (MRSA) infections may be associated with lower DAIR success rate. To the contrary, early surgery, radical debridement, exchange of removable components, washing with iodine and vacuum sealing drainage (VSD) may improve the success rate of DAIR. A sinus tract may not be absolutely contraindicated, but surgeons should treat it with caution. As there is no consensus on many issues, more high-quality research is required.

Do Prosthetic Joint Infections Worsen the Functional Ambulatory Outcome of Patients with Joint Replacements? A Retrospective Matched Cohort Study

OBJECTIVES

To assess the effect on the functional ambulatory outcome of postoperative joint infection (PJI) cured at the first treatment attempt versus not developing PJI in patients with hip and knee prostheses.

METHODS

In a single-hospital retrospectively matched cohort study, each patient with PJI between 2007 and 2016 was matched on age, sex, type of prosthesis and year of implantation with two other patients with uninfected arthroplasties. The definition of a PJI cure included infection eradication, no further surgical procedures, no PJI-related mortality and no suppressive antibiotics. Functional ambulatory status evaluated one year after the last surgery was classified into four simple categories: able to walk without assistance, able to walk with one crutch, able to walk with two crutches, and unable to walk. Patients with total hip arthroplasties (THA), total knee arthroplasties (TKA) and partial hip arthroplasty (PHA) were analysed separately.

RESULTS

A total of 109 PJI patients (38 TKA, 41 THA, 30 PHA) and 218 non-PJI patients were included. In a model adjusted for clinically relevant variables, PJI was associated with a higher risk of needing an assistive device for ambulation (vs. walking without aid) among THA (adjusted odds ratio (OR) 3.10, 95% confidence interval (95% CI) 1.26-7.57; p = 0.014) and TKA patients (OR 5.40, 95% CI 2.12-13.67; p < 0.001), and with requiring two crutches to walk or being unable to walk (vs. walking unaided or with one crutch) among PHA patients (OR 3.05, 95% CI 1.01-9.20; p = 0.047).

CONCLUSIONS

Ambulatory outcome in patients with hip and knee prostheses with postoperative PJI is worse than in patients who do not have PJI.

Enhancing Antibacterial Performance and Biocompatibility of Pure Titanium by a Two-Step Electrochemical Surface Coating

A two-step electrochemical surface treatment has been developed to modify the CP Ti surface on commercially pure titanium grade 2 (CP Ti): (1) anodic oxidation to form TiO₂ nanotube precoatings loaded with silver (Ag) and (2) microarc oxidation (MAO) to produce a porous Ca-P-Ag coating in an electrolyte containing Ag, Ca, and P. One-step MAO in the same electrolyte has also been used to produce porous Ca-P-Ag coatings without anodic oxidation and preloaded Ag as a control. Surface morphologies and alloying chemistry of the two coatings were characterized by SEM, EDS, and XPS. Biocompatibility and antimicrobial properties have been evaluated by the MTT method and co-culture of Staphylococcus aureus, respectively. It is demonstrated that porous coatings with high Ag content can be achieved on the CP Ti by the two-step treatment. The optimized MAO voltage for excellent comprehensive properties of the coating is 350 V, in which a suitable chemical equilibrium between Ag, Ca, and P contents and a Ca/P ratio of 1.67 similar to HA can be obtained, and the Ag particles are in the size of less than 100 nm and embedded into the underneath of the coating surface. After being contacted with S. aureus for 1 and 7 days, the average bactericidal rates were 99.53 and 89.27% and no cytotoxicity was detected. In comparison, the one-step MAO coatings contained less Ag, had a lower Ca/P ratio, and showed lower antimicrobial ability than the two-step treated samples.