Debridement, antibiotics, and implant retention (DAIR) is a viable treatment option for acute periprosthetic joint infections (PJI). The landmark DATIPO trial of Bernard et al. concluded that six weeks is not non-inferior to 12-week antibiotic therapy for DAIR. However, it is unknown if suppressive antibiotic treatment (SAT) would improve patient outcomes. Therefore, our study aims to evaluate the utility of SAT after 12 weeks of therapy. We performed a retrospective study of patients with acute hip or knee PJI managed with DAIR at five institutions; in the U.S. (n=1), Netherlands (n=3), and Spain (n=1) from 2005–2020. We analyzed the effect of SAT using a Cox model among patients after 12 weeks of antibiotic treatment. The primary covariate of interest was whether the patient was on antibiotics after week 12, which was coded as a time-varying covariate. We decided a-priori to control for the clinically important risk factors such as age, sex, type of infection, modular exchange, joint, and presence of bacteremia and Aim
Method
Two-stage replacement is a frequent procedure in patients with chronic PJI. However, results in the literature after this procedure differ, ranging from 54% to 100% of infection eradication. Positive cultures at reimplantation, when performing the second stage, are perceived as a risk factor for reinfection. This study aims to determine the impact of positive cultures during the second stage on the outcome of patients undergoing a 2-stage septic replacement and the impact of antibiotic holidays between the first and the second stage. We systematically searched four databases from inception to May 31, 2022. We combined terms related to PJI, joint replacement and culture results. We analysed the risk of failure when positive cultures at second stage and performed a subgroup analysis by antibiotic holiday period.Aim
Method
Our aim was to evaluate the prevalence and impact of unexpected intraoperative cultures on the outcome of total presumed aseptic knee and hip revision surgery. Data regarding patients prospectively recruited in our center, who had undergone elective complete hip and knee revision surgery from January 2003 to July 2017 with a preoperative diagnosis of aseptic loosening was retrospectively reviewed. Partial revisions and patients with follow up below 60 months were excluded from the study. The protocol of revision included at least 3 intraoperative cultures. Failure was defined as the need for re-revision due to any-cause at 5 years and/or the need for antibiotic suppressive therapy.Aim
Method
Patients with late acute periprosthetic joint infections (PJI) and treated with surgical debridement have a high failure rate. Previous studies have shown that rheumatoid arthritis (RA) is an independent risk factor for treatment failure. We conducted a case-control study to identify predictors for failure in late acute PJI treatment in RA patients. We hypothesize that patients with RA have a higher failure rate compared to controls due to the use of immunosuppressive drugs. Data of an international multicenter retrospective observational study was used. Late acute PJI was defined as a sudden onset of symptoms and signs of a PJI, more than 3 months after implantation. Failure of treatment was defined as persistent signs of infection, relapse with the same or reinfection with a different micro-organism, need for prosthesis removal or death. Cases with RA were matched with cases without RA based on the affected joint. A Cox survival analyses, stratified for RA, was used to calculate hazard ratio's (HR) for failure. Subgroup analyses were used to explore other predictors for treatment failure in RA patients.Aim
Method
Acute soft tissue defects (wound dehiscence or necrosis) after a total knee arthroplasty (TKA) may be the cause of the devasting complication of deep infection. When a medium (4–6cm) defect is present, in patellar or infra-patellar localization, a medial hemi-gastrocnemius flap is widely used to cover it, because of its low morbidity and high functional results. Normally, this coverage is not associated to a debridement, antibiotics and implant retention surgery (DAIR). When facing this situation, we should consider associating to the coverage treatment, like muscle flap, a DAIR procedure, in order to treat the possible acute infection, even when the diagnosis of infection is not clear. We could not find any studies comparing the benefice of this association in the same surgical act to isolated treatment of soft tissue defects. Our hypothesis was that when a TKA surgical wound defect is present, the risk of an acute infection is elevated and the patient would benefit from a muscle flap with DAIR procedure and polyethylene exchange. We performed a retrospective study to compare TKA infection clearance in patients with DAIR and flap in the same surgical act against those who received an isolated flap procedure for soft tissue coverage after an acute surgical wound defect. Patients were identified from a prospectively collated TKA database. Between 2005 and 2021, 19 patients met our inclusion criteria. A medial hemi-gastrocnemius flap was performed in 15 patients (78%). Healing or TKA infection clearance was defined as the presence of the original prosthesis after soft tissue coverage intervention, no need of DAIR after soft tissue coverage or no suppressive antibiotic treatment.Background
Methods
There have been many attempts to define the criteria by which prosthetic joint infection (PJI) is diagnosed. Our aim is to validate the 2021 European Bone and Joint Infection Society (EBJIS) definition of PJI. This is a multicenter retrospective study of patients who have undergone total hip or knee revision surgery in four different European institutions between 2013–2018. Cases with less than four intraoperative microbiology samples; no preoperative/intraoperative synovial fluid differential leukocyte count or intraoperative histology were excluded. Minimum follow-up of at least two years after revision surgery if no subsequent infection and/or the need for implant removal was also required. All cases were classified using the 2021 EBJIS, the 2018 International Consensus Meeting (ICM) and the 2013 Musculoskeletal Infection Society (MSIS) PJI definitions.Aim
Method
Rifampin is considered as the antibiotic corner stone in the treatment of acute staphylococcal periprosthetic joint infections (PJI). However, if, when, and how to use rifampin has been questioned. We evaluated the outcome of patients treated with and without rifampin, and analysed the influence of timing, dose and co-antibiotic. Acute staphylococcal PJIs treated with surgical debridement between 1999 and 2017, and a minimal follow-up of 1 year were evaluated. Treatment failure was defined as the need for any further surgical procedure related to infection, PJI-related death, or the need for suppressive antimicrobial treatment.Aim
Method
Accurate diagnosis is key in correctly managing prosthetic joint infection (PJI). Our aim is to compare the preoperative performance of three PJI definitions comparing it to definitive postoperative classification. This is a multicenter retrospective study of patients who have undergone total hip or knee revision surgery in four different European institutions. For this specific study, cases with no preoperative synovial fluid differential leukocyte count and less than four intraoperative microbiology samples were excluded. Cases were classified using the 2021 EBJIS, the 2018 International Consensus Meeting (ICM) and the 2013 Musculoskeletal Infection Society (MSIS) PJI definitions. Preoperative classification was based on clinical features, inflammatory markers and synovial fluid leukocyte count and microbiology results.Aim
Method
The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition. This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance.Aims
Methods
Failure of irrigation and debridement (I&D) for prosthetic joint infection (PJI) is influenced by numerous host, surgical, and pathogen-related factors. We aimed to develop and validate a practical, easy-to-use tool based on machine learning that may accurately predict outcome following I&D surgery taking into account the influence of numerous factors. This was an international, multicentre retrospective study of 1,174 revision total hip (THA) and knee arthroplasties (TKA) undergoing I&D for PJI between January 2005 and December 2017. PJI was defined using the Musculoskeletal Infection Society (MSIS) criteria. A total of 52 variables including demographics, comorbidities, and clinical and laboratory findings were evaluated using random forest machine learning analysis. The algorithm was then verified through cross-validation.Aims
Methods
Treatment success of debridement, antibiotics and implant retention (DAIR) is in early periprosthetic joint infection (PJI) is largely dependent on the presence or absence of a mature biofilm. In what time interval a mature biofilm develops is still unclear, and therefore, the time point at which DAIR should be disrecommended remains to be established. This large multicenter trial evaluated the failure rates of DAIR for different time intervals from index arthroplasty to DAIR in early PJI. We retrospectively evaluated patients with early PJI treated with DAIR between 1996 and 2016. Early PJI was defined as a PJI that developed within 90 days after index arthroplasty. Patients with hematogenous infections, arthroscopic debridements and a follow-up less than one year were excluded. Treatment failure was defined as 1) any further surgical procedure related to infection 2) PJI-related death, or 3) long-term suppressive antibiotics, all within one year after DAIR.Aim
Method
Gram negative bacteria (GNB) are emerging pathogens in chronic post-traumatic osteomyelitis. However, data on multi-drug (MDR) and extensively drug resistant (XDR) GNB are sparse. A multi-centre epidemiological study was performed in 10 countries by members of the ESGIAI (ESCMID Study Group on Implant Associated Infections). Osteosynthesis-associated osteomyelitis (OAO) of the lower extremities and MDR/XDR GNB were defined according to international guidelines. Data from 2000 to 2015 on demographics, clinical features, microbiology, surgical treatment and antimicrobial therapy were retrospectively analyzed. Cure was assessed after the end of treatment as the absence of any sign relevant to OAO. Factors associated with cure were evaluated by regression analysis.Aim
Methods
Late acute prosthetic joint infections (PJI) treated with surgical debridement and implant retention (DAIR) have a high failure rate. The aim of our study was to evaluate treatment outcome in late acute PJIs treated with DAIR versus implant removal. In a large multicenter study, late acute PJIs were retrospectively evaluated. Failure was defined as: PJI related death or the need for prosthesis removal or suppressive antibiotic therapy because of persistent or recurrent signs of infection. Late acute PJI was defined as < 3 weeks of symptoms more than 3 months after the index surgery.Aim
Method
A two-stage exchange of an infected prosthetic joint (PJI) is considered the most effective surgical treatment of chronic PJIs, particularly in North America. However, reinfection rates are unacceptably high (10–20%). This could be the consequence of a persistent infection or a new infection introduced during the first or second stage of the exchange arthroplasty. We aimed to determine: i) the prevalence of positive cultures at reimplantation, ii) whether there is an association between positive cultures at reimplantation and reinfection during follow-up, and iii) if there is a microbiological correlation between primary infections, reimplantations and reinfections. We retrospectively evaluated all two-stage exchange procedures performed at two academic centers between 2000 and 2015. Primary culture-negative PJIs and cases in whom no intraoperative cultures were obtained during reimplantation were excluded from the analysis. One or more positive intraoperative cultures during reimplantation were considered positive for infection. Reinfection was defined as the need for additional surgical intervention after reimplantation or the need for antibiotic suppressive therapy due to persistent clinical signs of infection.Aim
Method
Debridement, antibiotics and implant retention (DAIR) is the recommended treatment for all acute prosthetic joint infections (PJI). However, the efficacy of DAIR and identification of risk factors for failure in patients with late acute PJI, is not well described. Patients diagnosed with late acute PJI between 2005 and 2015 were retrospectively evaluated. Late acute PJI was defined as the development of acute symptoms (≤ 3 weeks) occurring ≥ 3 months after arthroplasty. Failure was defined as: i) the need for implant removal, ii) infection related death, iii) the need for suppressive antibiotic therapy due to persistent signs of infection and/or iv) relapse or reinfection during follow-up.Aim
Method
Debridement, antibiotics and implant retention (DAIR) is a widely used treatment modality for early acute prosthetic joint infection (PJI). A preoperative risk score was previously designed for predicting DAIR failure, consisting of chronic renal failure (K), liver cirrhosis (L), index surgery (I), cemented prosthesis (C) and C-reactive protein >115mg/L (KLIC). The aim of this study was to validate the KLIC score in an external cohort. We retrospectively evaluated patients with early acute PJI treated with DAIR between 2006 and 2016 in three Dutch hospitals. Early acute PJI was defined as less than 21 days of symptoms and DAIR performed within 90 days after index surgery. Failure was defined as the need for 1) second DAIR, 2) implant removal, 3) suppressive antimicrobial treatment or 4) infection-related death within 60 days after debridement.Aim
Method
Data on Prosthetic joint infection (PJI) caused by multi-drug resistant (MDR) or XDR (extensively drug resistant) Gram negative bacteria (GNB) are limited. Treatment options are also restricted. We conducted a multi-national, multi-center assessment of clinical data and factors of outcome for these infections. PJI were defined upon international guidelines. Data from 2000–2015 on demographics, clinical features, microbiology, surgical treatment and antimicrobial therapy was collected retrospectively. Factors associated with treatment success were evaluated by logistic regression analysis.Aim
Method
Septic arthritis of the hip is a rare entity among the adult population, but with a potential severe repercussion. The most accepted treatment is the hip debridement, even though a notorious proportion of the cases need further hip replacement owing to the cartilage destruction. The aim of this study is to analyse all our cases of septic arthritis of the hip treated with a 2-stage strategy using an antibiotic-loaded cement spacer. We present a retrospective review of all our cases of septic arthritis of the hip diagnosed between 2004 and 2016 that were treated with an antibiotic-loaded cement spacer. We analysed age, gender, comorbidities, aetiology, duration of symptoms, C-reactive protein values, erythrocyte sedimentation rate, initial treatment, cultures, definitive treatment and evolution.Aim
Method
Patient safety is a major concern worldwide, but particularly high rates of adverse events are reported in the surgery setting. Orthopaedic and Traumatology is the speciality most frequently involved in claims in Catalonia. The objective of the study is to perform a descriptive study of the claims regarding infection in Orthopaedic and Traumatology in Catalonia. We performed a retrospective study of the claims regarding infection in Orthopaedic and Traumatology from the prospective claims database of the Service of Professional Liability of The Catalonian Council of Official Colleges of Physicians. The time frame of data collection was from 2003 to 2013. We analyzed both the clinical and legal characteristics of the cases. During the 10-year period, 638 registered claims were related to the practice of Orthopaedic and Traumatology, and 74 (11,6%) were due to infection. The most frequent surgical procedure involved were arthroplasty (knee, hip or shoulder) (14, 18,9%), traumatic wounds and cellulitis (12, 16,2%), spine procedures (10, 13,5%) and arthroscopy (7, 9,4%). The most frequent anatomical site involved were foot and ankle (17, 22,9%), spine (15, 20,3%), knee (14, 18,9%), wrist and hand (11, 14,8%). The 68,92% of claims was solved by the courts and 29,73% by an “out-of-court” procedure. The average compensation in cases considered to have professional liability was 145.045€. Orthopaedic and Traumatology seem to be a specialty with a high risk for claims, and infection is one of the most important causes. The study of the claims can lead to improvements in prophylaxis, diagnosis and treatment of infection in Orthopaedic and Traumatology.
Open debridement, irrigation with implant retention and antibiotic treatment (DAIR) is an accepted approach for early prosthetic joint infections (PJI). Our aim was to design a score to predict patients with a higher risk of failure. From 1999 to 2014 early (<90 days) PJIs without signs of loosening of the prosthesis were treated with DAIR and were prospectively collected and retrospectively reviewed. The primary end-point was early failure defined as: 1) the need of an unscheduled surgery, 2) death-related infection within the first 60 days after debridement or 3) the need for suppressive antibiotic treatment. A score was built-up according to the logistic regression coefficients of variables available before debridement. A total of 222 patients met the inclusion criteria. The most frequently isolated microorganisms were coagulase-negative staphylococci (95 cases, 42.8%) and Staphylococcus aureus (81 cases, 36.5%). Fifty-two (23.4%) cases failed. Independent predictors of failure were: chronic renal failure (OR:5.92, 95%CI:1.47–23.85), liver cirrhosis (OR:4.46, 95%CI:1.15–17.24), revision surgery (OR:4.34, 95%CI:1.34–14.04) or femoral neck fracture (OR:4.39, 95%CI:1.16–16.62) compared to primary arthroplasty, CRP >11.5 mg/dL (OR:12.308, 95%CI:4.56–33.19), cemented prosthesis (OR:8.71, 95%CI:1.95–38.97) and when all intraoperative cultures were positive (OR:6.30, 95%CI:1.84–21.53). Furthermore, CRP showed a direct relationship with the percentage of positive cultures (Linear equation, R2=0,046, P=0.002) and an inverse association with the time between the debridement and failure (Logarithmic equation, R2=0.179, P=0.003). A score for predicting the risk of failure was done using pre-operative factors (KLIC-score, figure 1) and it ranged between 0–9.5 points. Patients with a score ≤2, >2–3.5, 4–5, >5–6.5 and ≥7 had a failure rate of 4.5%, 19.4%, 55%, 71.4% and 100%, respectively. The KLIC-score was highly predictive of early failure after debridement. In the future, it would be necessary to validate our score using cohorts from other institutions.
Early prosthetic joint infections (PJI) are managed with debridement, implant retention and antibiotics (DAIR). Our aim was to evaluate risk factors for failure after stopping antibiotic treatment. From 1999 to 2013 early PJIs managed with DAIR were prospectively collected and retrospectively reviewed. The main variables potentially associated with outcome were gathered and the minimum follow-up was 2 years. Primary endpoint was implant removal or the need of reintroducing antibiotic treatment due to failure. A total of 143 patients met the inclusion criteria. The failure rate after a median (IQR) duration of oral antibiotic treatment of 69 (45–95) days was 11.8%. In 92 cases PJI was due to gram-positive (GP) microorganisms, in 21 due to gram-negatives (GN) and 30 had a polymicrobial infection. In GP infections, combination of rifampin with linezolid, cotrimoxazole or clindamycin was associated with a higher failure rate (27.8%, P=0.026) in comparison to patients receiving a combination of rifampin with levofloxacin, ciprofloxacin or amoxicillin (8.3%) or monotherapy with linezolid or cotrimoxazole (0%) (Figure 1). Among patients with a GN infection, the use of fluoroquinolones was associated with a lower failure rate (7.1% vs 37.5%, P=0.044). Duration of antibiotic treatment was not associated with failure. The only factor associated with failure was the oral antibiotic selection, but not the duration of treatment. Linezolid, cotrimoxazole and clindamycin but not levofloxacin serum concentrations are reduced by rifampin; a fact that could explain our findings. Further studies monitoring serum concentration could help to improve the efficacy of these antibiotics when combining with rifampin.
Stored red blood cells (RBCs) undergo a variety of changes that impair their post-transfusion viability, but the detrimental effect of such lesion at the clinical level is a matter of debate (1) and there is no data about the incidence of postoperative infection, a complication frequently associated with transfusion of stored RBCs (2). We reviewed 9906 patients who underwent a primary or revision arthroplasty between January 2000 and December 2012. Of these, 1153 (11.6%) received transfusion during surgery or within the first 6h after surgery (early transfusion, ET) and 920 (9.3%) received transfusion only between 24 and 96 hours after surgery (late transfusion, LT). Primary end-point was prosthetic joint infection (PJI) within the first year. Demographics, joint, type of surgery, duration of surgery, number and length of storage of transfused RBCs were collected. Ethical Committee approved the study. The median age was 74.9 (IQR:68.3–80.1) years and 1546 (74.6%) were female. There were 914 (44.1%) hip and 1117 (53.9%) knee arthroplasties and 428 (20.6%) were revision surgeries. The median duration of surgery was 105 (IQR:80–145) minutes. A total of 100 (4.8%) patients had a PJI. Figure 1 shows the PJI rate according to the number of RBC units transfused and the proportion of such units that had been stored for more than 14 days, both in the ET-group (Fig. 1A) and the LT-group (Fig. 1B). In the ET-group, the fact that >50% of transfused RBCs had been stored >14 days was an independent predictor of PJI (OR:2.50, 95%CI:1.44–4.33, Hosmer-Lemeshow test P=0.972). Stored RBC occlude the microcirculation (1), thereby precluding a good oxygenation of the surgical wound and the arrival of leukocytes and prophylactic antibiotics. Both factors are involved in the progression from wound bacterial contamination to wound infection and are particularly operative in the few hours following surgery (5). It is biologically plausible that transfusion of old RBC in this early, critical period results in more wound infections as compared to RBCs transfused later.
patients submitted to hip revision arthroplasty due to an aseptic loosening in whom cultures (at least 5) obtained during surgery were negative and patients submitted to hip revision arthroplasty due to a septic loosening confirmed by the presence of pus or ≥2 positive culture for the same microorganism.
Exchange of infected implant using antibiotic-impregnated cement is the treatment of choice in prosthetic joint infection (PJI). We presented our experience using one or two-stage exchange with uncemented implants. From January 2000 to June 2006 patients with a PJI that were treated with one or two-stage exchange with uncemented implants, were prospectively followed up. The treatment protocol consisted of radical excision of devitalized tissue and of maintaining a high serum antibiotic concentration during surgery followed by systemic antibiotic administration according to the microbiology results. Only patients with ≥6 months of follow-up were included. Good evolution was considered when symptoms and signs of infection disappeared and the C-Reactive Protein was normal. Forty-two patients were included in the study, of whom 25 were male. The mean age was 70 years. The most common symptom was pain (100%) and radiological signs of prosthesis loosening were present in 36 cases (85.7%). Histology was positive in 32 patients (76.2%). Coagulase-negative staphylococci was the most common microorganism (23 cases) followed by S. aureus (5 cases). One-stage exchange was performed in 18 patients, and the long stem component was always uncemented. In one case an acute infection after the arthroplasty obligated to perform an open debridément without implant removal. After a mean follow-up of 31 months (range: 6–84) all patients had a good evolution. In 24 cases a 2-stage exchange with a joint spacer with gentamycin (Spacer-G) was performed. In all cases the definitive arthroplasty was performed using an uncemented long stem. Good evolution was documented in all but one case with persistent infection due to S. aureus after a mean follow-up of 19 months (range: 12–48). Our results suggest that uncemented arthroplasty following a protocol based on radical debridément and systemic antibiotic therapy during and after surgery is a useful approach in PJI.
In primary total knee arthroplasty (TKA) performed under ischemia the antibiotic prophylaxis is administered 15’ before inflating the tourniquet. The infection rate in TKA is higher than in hip arthroplasty. We hypothesise that ischemia could impair the efficacy of the antibiotic. The objective of our study was to compare the effectiveness of two schedules of antibiotic administration. We conducted a randomised and a double blind study. Patients were assigned to receive placebo 15’ before inflating tourniquet and cefuroxim 1.5 g 10’ before releasing the tourniquet (experimental arm) or cefuroxim 1.5 g 15’ before inflating tourniquet and placebo 15’ before releasing tourniquet (standard arm). In both arms cefuroxime 1.5 g was administered 6 hours after finishing surgery. The variables gathered were: age, sex, indication for TKA, co-morbidity, ASA score, duration of the operation, number of blood transfusions, days of hospitalisation and number of surgical site infections after 3 months of surgery. Categorical variables were compared using the χ2 test or the Fisher exact test and quantitative variables using Student-t test. Nine hundred and eight patients were randomised and 466 and 442 patients were allocated to experimental and standard arms respectively. Both groups were similar and there were no differences in deep and superficial infection rates, 1.39% and 4.18% for experimental arm and 3.39% and 3.17% for standard arm (p>
0.05). The experimental arm had a lower global and deep infection rate than the standard arm when the length of surgery was lower than the 75th percentile (global: 4.03 vs 7.93%, p=0.04, deep: 1.72% vs 4.44%, p=0.07). The administration of antibiotic prophylaxis 10’ before releasing the tourniquet decreases the surgical site infection rate when the duration of surgery is lower than the 75th percentile.
Intraoperative histology has a high specificity and sensitivity to identify prosthetic joint infection. However, the usefulness of this technique according to the type of microorganism isolated in the periprosthetic tissue has not previously been studied. Frozen sections and cultures from periprosthetic tissue of 38 revision arthroplasties performed due to prosthetic joint infection were retrospectively reviewed. Frozen sections were evaluated according to Mirras’ criteria (adapted by Feldman). Culture was considered positive when the same microorganism was isolated in at least 2 samples or the presence of pus around the prosthesis. Coagulase-negative staphylococci (CNS) was the aetiology in 13 cases, Gram-negative bacilli in 8, S. aureus in 7, Candida sp and Peptococcus sp in 2 and Enterococcus sp, S.pneumoniae and in 1 case each one. No microorganism was isolated in 4 cases. Frozen sections revealed more than 5 neuthrophils per high power field (forty times) in at least five fields in all cases except in 2 out of 13 caused by CNS (15.3%). A revision of the articles that provided information on the aetiology and the histology supports the findings of our study. In conclusion, frozen section using Feldman’s criteria had a 15.3% of false negative cases when CNS was the aetiology of the prosthetic joint infection.
