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BACKGROUND AND OBJECTIVES: Periprosthetic joint infections (PJIs) that occur after hip and knee arthroplasty have a major influence on patient outcomes and healthcare expenses. This study assesses the effectiveness of the PJI tumor, node, and metastasis (PJI-TNM) categorization system and the latest developments in local antibiotic delivery methods for the treatment of PJIs. MATERIALS AND METHODS: The study involved a retrospective analysis of 23 patients who received treatment for septic hip or knee prostheses at the SUUB Orthopedics and Traumatology Clinic between January 1, 2022, and February 10, 2024. Approval was gained following ethical considerations. Patients were categorized using the PJI-TNM system, and their therapy was customized based on the severity of the infection. The surgical procedures involved either one-stage or two-stage revisions, utilizing vancomycin and gentamicin antibiotic-loaded calcium sulfate beads to administer antibiotics locally. Data pertaining to demographics, clinical characteristics, and microbiology were gathered and examined. RESULTS: The study comprised 14 male and 9 female patients, with an average age of 68 years. The presence of chronic infections was mostly seen, indicating the development of mature biofilm. Prevalent coexisting medical conditions included diabetes, obesity, and heart failure. The duration of infection control measures was, on average, six months, and 65% of patients reported experiencing enhanced mobility. Acute infections with positive antibiotic responses underwent one-stage modifications. For the majority of patients, a treatment approach involving two-stage modifications, which includes the use of antibiotic-loaded spacers followed by the installation of a prosthesis, proved to be beneficial. CONCLUSIONS: The PJI-TNM classification system improves the management of PJI by offering a systematic method for customized therapy. Calcium sulfate beads, which are biodegradable carriers for antibiotics, provide notable advantages, especially for individuals with severe comorbidities. Continuous progress in diagnostic techniques and localized administration of antibiotics is essential for enhancing the therapy of PJI and improving patient outcomes.

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INTRODUCTION: Revision hip arthroplasty in the presence of complex acetabular deficiencies is challenging. Cement, allograft, reconstruction rings and porous trabecular metal now provide versatile options for acetabular fixation and restoration of acetabular offset. We compare acetabular impaction bone grafting (AIBG) and trabecular metal (TM) cups at long-term follow-up. METHODS: 53 patients who underwent revision hip arthroplasty were retrospectively reviewed from local joint registry data. 36 patients were revised using AIBG and 17 with TM. Median clinical follow-up was 9.57 (2.46-18.72) years and 9.65 (7.22-12.46) years, respectively. 82% of the TM group and 63% of the AIBG group were ⩾ Paprosky 2C. Re-revision was considered failure. Radiographs demonstrating 5 mm of femoral head migration and 5° of acetabular component inclination change were considered loose. RESULTS: Patients receiving AIBG were younger (68 vs. 74 years) with a longer interval from initial arthroplasty to revision (17 vs. 13 years). Revisions in both groups were indicated most commonly for failed cementing (AIBG 88.9% vs. TM 70.5%). No TM reconstructions underwent re-revision, with only 1 failing at 6.3 years, compared with 9 AIBG re-revisions. When revising for sepsis, 33% of AIBG revisions failed. CONCLUSIONS: AIBG demonstrated high failure rates at long-term follow-up when compared to TM constructs. We recommend the use of AIBG in small cavitary defects only. We strongly advise against its use in the setting of significant bony defects and for prosthetic joint infection.

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Staphylococcus aureus (S. aureus), an opportunistic Gram-positive bacterium, is notorious for causing a plethora of clinical diseases. While it does not typically infect healthy skin, S. aureus infections are prevalent in both community-acquired and hospital-acquired settings. Rheumatoid arthritis (RA), a chronic autoimmune disease characterized by joint inflammation and progressive bone erosion, can be managed medically and, in moderate to severe cases, surgically through arthroplasty. Complications of arthroplasty include wound infection, blood clots, stiffness, and infection around the prosthesis. Prosthetic joint infections (PJIs) are a rare complication of arthroplasty, commonly caused by aerobic Gram-positive bacteria. These infections can lead to bacteremia, precipitating a cascade of adverse clinical sequelae. This report aims to explore the etiology of delayed-onset PJIs, the underlying pathophysiology of this condition leading to bacteremia, the complications of S. aureus bacteremia, and the management strategies employed to treat PJIs and complicated cases of S. aureus bacteremia resulting from PJIs.

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BACKGROUND: Surgical techniques in two-stage revision total knee arthroplasty (rTKA) include the use of articulating spacers and static spacers. Shortening of the patellar tendon could be a reason for inferior functional outcomes in two-stage septic rTKA . The aim of this study was to determine if articulating spacers also have negative effects on the extensor mechanism in rTKA. METHODS: This retrospective study includes 65 consecutive patients (23 women, 42 men, age 71.3 ± 1.2; range, 51.2-88.6 years) undergoing septic two-stage rTKA using an articulating spacer between 2014 and 2021 in a single orthopedic center. For all patients, calibrated true lateral radiographs before total knee arthroplasty (TKA) explantation (T0), directly after TKA explantation (T1), shortly before TKA reimplantation (T2) and 6-8 days after TKA reimplantation (T3) were used to calculate the modified Insall Salvati ratio (mISR). RESULTS: Overall, the mISR decreased significantly immediately after explantation (T0 vs. T1, p = 0.002) from 1.43 ± 0.03 to 1.36 ± 0.03 and remained stable until T2 (1.37 ± 0.02, p = 0.74). Following TKA reimplantation, the mISR increased again to 1.43 ± 0.03 (T3). There were no significant differences between T0 and T3 (p = 0.88). Six out of 65 patients (9%) experienced patellar tendon shortening > 10% at T3. CONCLUSIONS: Septic two-stage revision TKA using an articulating spacer does not lead to patellar tendon shortening in the majority of cases. This study suggests that one reason for the improved range of motion after reimplantation may be the use of articulating spacers compared to static spacers.

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Background: This study aims to assess the activity of solutions containing povidone-iodine (PI) and hydrogen peroxide (H2O2) alone or combined on the biofilm of microbial species in the contest of periprosthetic joint infection (PJI). Methods: Different antiseptic solutions were tested on 2-day-old biofilms of Gram-positive and Gram-negative bacteria and fungi at 1 and 3 minutes of exposure. The efficacy of these solutions was evaluated by measuring the biofilm metabolic activity by methoxynitrosulfophenyl-tetrazolium carboxanilide (XTT) reduction assay. The anti-biofilm effect of 5% PI and 0.3% PI + 0.5% H2O2 was tested on a 5-day-old biofilm using colony-forming unit counts and an XTT reduction assay. Results: PI and H2O2 solutions showed concentration-dependent anti-biofilm activity except for E. faecalis. PI at 5% was the most active solution against the 2-day-old biofilm of all test microorganisms. The 0.3% PI + 0.5% H2O2 solution had a significant effect only at 3 minutes. The 5% PI and 0.3% PI + 0.5% H2O2 effect was evaluated on 5-day-old biofilms. PI at 5% produced a significant reduction in metabolic activity at both 1 and 3 minutes; 0.3% PI + 0.5% H2O2 caused a significant activity against all Gram-positive strains after 3 minutes, with a greater metabolic activity reduction than 5% PI. Conclusions: In the case of PJI caused by Gram-positive bacteria, 0.3% PI + 0.5% H2O2 could be used for wound irrigation for 3 minutes of exposure. In the case of PJI with a different etiological agent or PJI with an unknown etiology, it is advisable to use 5% PI for 1 minute of exposure.

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Total hip arthroplasty (THA) is a highly successful operation performed worldwide in increasing numbers for a wide range of indications. There has been a corresponding rise in the incidence of periprosthetic joint infection of the hip (PJIH), which is a devastating complication. There is a significant variation in the definition, diagnosis and management of PJIH largely due to a lack of high-level evidence. The current standard of practice is largely based on cohort studies from high-volume centres, consensus publications amongst subject experts, and national guidance. This review describes our philosophy and practical approach of managing PJIH at a regional tertiary high-volume joint replacement centre.

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Increasing antibiotic resistance has been reported as an issue in the treatment of periprosthetic joint infection (PJI). A repeat two-stage revision for recurrent PJI is at high risk of reinfection. However, it is unclear if the microorganism profile plays a role with potentially more resistant or polymicrobial infections. This is a retrospective, single-center analysis of two-stage revisions performed between 2011 and 2017. We identified 46 patients who underwent a repeat resection arthroplasty for recurrent PJI of the same joint after a previous two-stage revision of the same joint at the same department. All microbiological findings were analyzed focusing on microbiological spectrum and resistance testing as well as the potential impact on reinfection-free survival. The most common organism found at the time of recurrent PJI were coagulase-negative Staphylococci (39%) followed by Gram-negative organisms (28%). The risk of polymicrobial infections, difficult-to-treat resistant organisms, and Gram-negative infections increased significantly. Among staphylococcal infections, there was a high percentage of methicillin-resistant species and resistance to oral antibiotics. Patients with Gram-negative organisms had a reduced infection-free survivorship, while resistant organisms were not associated with decreased survival. Patients who undergo a repeat two-stage revision for recurrent PJI have more polymicrobial and resistant organisms, although the impact on survivorship is unclear.

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One of the complications after total hip arthroplasty (THA) or total knee arthroplasty (TKA) is periprosthetic joint infection (PJI). Numerous studies have been performed to explore the value of biological parameters in the early identification of infection rates after THA and TKA. This study investigates alterations in inflammatory markers associated with PJI. This retrospective study focused on a cohort of patients with hip and knee arthroplasty treated between 2016 and 2022. CRP, ESR, and fibrinogen were observed preoperatively, on days one, three, six, and twenty-one postoperatively. From a total of 4076 THA and TKA performed during this period, 62 patients were identified with periprosthetic infections. We also identified the pathogens responsible for infections in order to assess if asymptomatic preoperative infections were involved in PJI. In patients with acute infections following TKA, days one and three postoperative recorded a CRP value below the expected range. The value of CRP in patients with early infection after THA was significantly increased on day six postoperative. ESR and fibrinogen values were not statistically significantly correlated with early PJI. The CRP level in acute PJI shows different patterns than those shown in the literature.

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Periprosthetic joint infections (PJI) pose a significant challenge in orthopaedic surgery, often requiring extensive surgical debridement and prolonged antibiotic treatment to eliminate the causative pathogens. Rifampin, known for its potent activity against biofilms, has been crucial in managing PJI by penetrating and disrupting these formations, thereby improving treatment efficacy. In this sense, antibiotic protocols lacking rifampin have shown increased failure rates. Consequently, the development of rifampin resistance could severely influence the prognosis of PJI. The aim of this clinical study was to assess how rifampin resistance affects the functional outcome in patients with PJI. In this single-centre comparative cohort study, we systematically documented all patients who presented with a PJI during the period spanning from 2018 to 2020. Two distinct groups were established for the study: Group 1 comprised 35 patients with a PJI caused by rifampin-susceptible pathogens and group 2 consisted of 28 patients with PJI caused by rifampin-resistant pathogens. A total of 63 patients (34 females) with a mean age of 68 years and a mean follow up of 37 months were included. The examination of patient-specific parameters did not reveal any identified risk factors as influential. Patients with a rifampin-resistant pathogen underwent a greater number of surgical revisions (6.9 ± 5.1 compared to 3.59 ± 3.39, p = 0.0011) and had extended durations of antibiotic treatment (p = 0.0052). The results of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score revealed significant differences in clinical outcome between both groups in every domain, even when stratified by acute and chronic entities. In total the WOMAC increased significantly from 21.57 ± 14.9 points in group 1 to 71.47 ± 62.7 points in group 2 (p < 0.001). The higher failure rates observed in group 2 were not statistically significant (p = 0.44). The current study demonstrates that PJI caused by rifampin-resistant bacteria are associated with a significantly worse functional outcome in both acute and chronic infection types without significantly affecting total failure rates.

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Implant surface nanofiber (NF) coatings represent an alternative way to prevent/treat periprosthetic joint infection (PJI) via local drug release. We developed and characterized a coaxial erythromycin (EM)-doped PLGA/PCL-PVA NF coating. The purpose of this study was to determine the efficacy of EM-NF coatings (EM0, no EM, EM100 (100 mg/mL), and EM1000 (1000 mg/mL) wt/wt) in a rat PJI model. A strong bond of the EM-NF coating to the surface of titanium (Ti) pins was confirmed by in vitro mechanical testing. Micro-computed tomography (mCT) analysis showed that both EM100 and EM1000 NF effectively reduced periprosthetic osteolysis compared to EM0 at 8 and 16 weeks after implantation. Histology showed that EM100 and EM1000 coatings effectively controlled infection and enhanced periprosthetic new bone formation. The bone implant contact (BIC) of EM100 (35.08%) was higher than negative controls and EM0 (3.43% and 0%, respectively). The bone area fraction occupancy (BAFO) of EM100 (0.63 mm2) was greater than controls and EM0 (0.390 mm2 and 0.0 mm2, respectively). The BAFO of EM100 was higher than that of EM1000 (0.3 mm2). These findings may provide a basis for a new implant surface fabrication strategy aimed at reducing the risks of defective osseointegration and PJI.

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Background: Microvascular occlusions caused by sickle-shaped erythrocytes in patients with sickle cell disease (SCD) can lead to increased intraoperative and postoperative complications during total hip arthroplasty (THA). This systematic review and meta-analysis aimed to estimate the overall rate of complications following THA in patients with SCD and to identify the predictors of these complications including the surgical approach. Methods: The search was conducted across the grey literature, Google Scholar, and seven databases: Scopus, MEDLINE Central/PubMed, ProQuest, SciELO, SAGE, and Web of Science. All observational studies reporting the proportional THA complications in SCD were included. The Newcastle-Ottawa Scale quality assessment tool was used to assess the quality of the studies. The random effect model was applied to estimate the pooled outcomes. A sub-group analysis for the different approaches was performed. A sensitivity analysis and meta-regression were used to explain heterogeneity and to identify the THA complication predictors. Results: Of 3230 citations, only 23 studies were eligible for the meta-analysis. The pooled proportion of total primary THA complications in patients with SCD was 42% (95% CI: 30-56%, I2 = 95%). The sub-group analysis highlighted the anterolateral approach as the approach accompanied with the least complications. The meta-regression revealed that the anterolateral approach decreases the complications significantly, -28.67 (95%CI, -56.45--0.88, p = 0.044), while the number of hips increased the complications by 0.43 (95%CI, 0.30-0.57, p < 0.001). Male gender, age, lateral approach, and HbSS non-significantly affect the THA complications in SCD 52.05, 0.18, 6.06, and 55.78, respectively. The pooled proportions for an SCD crisis 9% (95%CI, 5-14%, I2 = 61%), dislocation 4% (95%CI: 2-7%, I2 = 66%), aseptic loosening 12% (95%CI, 7-20%, I2 = 91%), revision 6% (3-11, I2 = 92%), heterotopic ossification 12% (95%CI, 3-35%, I2 = 95%), and prosthetic joint infection (PJI) 6% (95%CI, 3-11%, I2 = 92%). The most fitted model of meta-regression illustrated that HbSS significantly increases PJI, 0.05 (95%CI: 0.02-0.08, p = 0.009), and male gender and age non-significantly increase PJI, 2.28 (95%CI: -4.99-13.56, p = 0.311) and 0.001 (95%CI: -0.27-0.27, p = 0.990), respectively. Meanwhile, the anterolateral, lateral, and posterior approaches non-significantly decrease PJI, -3.55, -0.92, and -1.27, respectively. The pooled proportion for a sickle cell disease crisis after revision was 16% (95%CI: 6-36%, I2 = 0) and for aseptic loosening after revision, it was 24% (95%CI: 12-43%, I2 = 0). Conclusions: This study revealed the high rate of complications in patients with SCD and highlighted that the anterolateral approach was associated with the lowest rate of complications. Furthermore, this study illustrated that homozygous (HbSS) individuals are more susceptible to prosthetic joint infection.

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BACKGROUND: A sinus tract is an abnormal channel that communicates between the skin and the joint, and meets one of the major criteria that is diagnostic of periprosthetic joint infection (PJI). The purpose of this study was to compare the risk factors and the microorganism profile of PJI of the knee with an overlying sinus tract to PJI without a sinus tract. METHODS: This was a retrospective case-control study of PJI following total knee arthroplasty with and without the presence of an overlying sinus tract from 1996 to 2020. There were 2,685 unique cases of chronic PJI following total knee arthroplasty, of which 405 cases (15.1%) had a sinus tract and 2,280 cases (84.9%) did not. Univariate and multivariate analyses were performed to evaluate risk factors and the microorganism profiles of the 2 groups. Odds ratios with 95% confidence intervals were reported. RESULTS: After adjusting for potential confounders in the multivariate analysis, the presence of a sinus tract was associated with a history of severe liver disease (P = .039; odds ratio: 1.99; 95% confidence interval: 1.04 to 3.84). Polymicrobial infections comprised 41.7% of PJI in the sinus tract group, compared to 29.1% in patients who did not have a sinus tract (P < .001). Of the monomicrobial PJI, Staphylococcus aureus (P < .001), Enterococcus faecalis (P < .001), Enterobacter cloacae (P = .002), Corynebacterium species (P = .037), Proteus mirabilis (P = .028), coagulase-negative Staphylococci (P = .019), and Candida albicans (P = .029) were more common in patients who had a sinus tract. CONCLUSIONS: The microbiology profile is significantly different in patients who have PJI of the knee with a sinus tract. These findings can guide the surgeon with surgical planning and selecting the appropriate antibiotic-loaded bone cement and empiric antibiotic treatment.

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PURPOSE: Searching for quick determinable biomarkers with high sensitivity and specificity is necessary to improve and optimise the early diagnosis of periprosthetic elbow infection (PEI). Therefore, this study's objective was to evaluate the diagnostic value of synovial fluid interleukin-6 (IL-6) levels for diagnosing PEI in total elbow arthroplasty. METHOD: Twelve prospective enrolled patients underwent total elbow arthroplasty revision surgery, during which synovial fluid was obtained. Between the initial implantation and the revision procedure were 33.5 ± 41 months (range, 2-144 months). Synovial fluid was collected for immediate IL-6 analysis parallel to the revision surgery. Furthermore, microbiological samples were obtained and analysed. Two groups were defined based on the microbiological results: non-infection and infection group. The ability of synovial fluid IL-6 analysis to predict infection status was explored using receiver operating characteristic curves and further statistical analysis. RESULTS: Synovial fluid IL-6 analysis had a good diagnostic accuracy of 83% for PEI with an area under the curve of 0,79 and an ideal cutoff value (determined using Youden's criterion) of 15244 pg/mL. DISCUSSION: This is the first study to clinically evaluate IL-6 as a diagnostical marker for periprosthetic joint infection (PJI) in total elbow arthroplasty. Our results suggest a good accuracy and high sensitivity for IL-6 to identify a PEI. The analysis of IL-6 can improve surgical decision-making regarding managing total elbow arthroplasty in terms of one- or two-staged revision. CONCLUSION: IL-6 can play an important role in the perioperative differentiation of infected and non-infected situations.

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BACKGROUND: Robot-assisted total knee arthroplasty (RA-TKA) has significantly improved knee surgery outcomes in the last few years. However, its association with the periprosthetic joint infection (PJI) rate remains debatable. This study investigates the incidence of early and delayed PJI in a multicentric cohort of patients who underwent RA-TKA, aiming to elucidate the risk associated with this procedure. METHODS: This retrospective study analyzed data from a consecutive series of patients who underwent RA-TKA using the NAVIO Surgical System (Smith & Nephew, Memphis, USA) between 2020 and 2023. The inclusion criteria encompassed individuals over 18 years of age with a minimum follow-up period of three months. The primary outcome was the incidence of early and delayed PJI, defined according to the European Bone and Joint Infection Society (EBJIS) diagnostic criteria. Secondary outcomes included the evaluation of postoperative complications. RESULTS: The study included patients who underwent RA-TKA with the NAVIO system, achieving an average follow-up of 9.1 ± 3.9 months. None of the patients met the EBJIS criteria for a likely or confirmed infection, indicating an absence of both early and delayed PJI cases. Two patients required subsequent surgical interventions due to patellar maltracking and prosthetic loosening, respectively. Additionally, three patients underwent passive manipulation under anesthesia (MUA). CONCLUSION: The findings indicate no evidence of early or delayed PJI in patients undergoing RA-TKA within the study period. The low complication rate further supports the reliability and safety of this surgical technique in short-term follow-up. LEVEL OF EVIDENCE: IV.

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Purpose: Pathogen identification is key in the treatment of septic arthritis (SA) and periprosthetic joint infections (PJI). This study evaluates the outcome of the application of a new, score-based SA and PJI diagnostic algorithm, which includes the execution of molecular testing on synovial fluid. Methods: A score-based diagnostic algorithm, which includes serologic and synovial fluid markers determination using multiplex PCR (mPCR) and Next Generation Sequencing (NGS) molecular testing, has been applied to a consecutive series of patients with clinically suspected SA or PJI. Patients with a score ≥6 underwent synovial fluid molecular testing, together with traditional culture, to identify the pathogen and its genetically determined antibiotic resistance. Results: One hundred and seventeen joints in 117 patients (62.5% women; average age 73 years) met the criteria for possible SA/PJI. The affected joint was the knee in 87.5% (joint replacement 66.5%; native joint 21%) and the hip in 12.5% (all replaced joints). 43/117 patients (36.7%) were ultimately diagnosed with SA/PJI. Among the various testing technologies applied, mPCR was the main determinant for pathogen identification in 63%, standard culture in 26%, and mNGS in 11%. Staphylococcus aureus and Enterococcus faecalis were the top two microorganisms identified by mPCR, while Staphylococcus epidermidis was the prevalent organism identified by NGS. mPCR detected the presence/absence of the genetically determined antibiotic resistance of all identified microorganisms. The average timeframe for pathogen identification was 3.13 h for mPCR, 4.5 days for culture, and 3.2 days for NGS. Conclusions: Molecular diagnostic technologies represent an innovative screening for fast microorganism identification when a joint infection is clinically suspected. Level of Evidence: Level IV, case series.

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Total joint arthroplasties (TJA) are some of the most commonly performed surgeries in the United States with the number of TJA expected to rise significantly over the next decade as the population ages and arthritic burden worsens. However, the rise in TJA volume correlates with a heightened risk of complications, notably prosthetic joint infections (PJI), despite their low occurrence rate of less than 2%. PJI imposes a significant burden on surgery success, patient well-being, and healthcare costs, with an estimated annual expense of 1.85 billion dollars for hip and knee PJI by 2030. This manuscript delves into the pathophysiology of PJI, exploring our current understanding of the role of bacterial biofilm formation on implanted foreign hardware, providing protection against the host immune system and antibiotics. The article reviews current agents and their efficacy in treating PJI, as well as their cytotoxicity toward native cells involved in wound healing, prompting the exploration of a novel citrate-based solution. The paper highlights the superior properties and efficacy of a novel citrate-based irrigation solution on the treatment and prevention of PJI via increased antimicrobial properties, greater biofilm disruption, increased exposure time, and reduced cytotoxicity compared to conventional solutions, positioning it as a promising alternative. It also provides a perspective on its clinical use in the operating theater, with a step-by-step approach in TJA, whether primary or revisionary.

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INTRODUCTION: Total joint arthroplasty (TJA) is a common procedure that improves the quality of life for severe arthritis patients. The rising demand for TJA places enormous financial strain on the world's healthcare systems, which is exacerbated by postoperative readmissions for complications such as periprosthetic joint infections (PJIs). We conducted a systematic review and meta-analysis to determine if asymptomatic bacteriuria (ASB) increases infection risk. METHODS: We conducted searches in three databases: PubMed, Scopus, and Web of Science. Screening steps have been carried out according to PRISMA guidelines. The study focused on patients who had undergone TJA and exhibited ASB. Two reviewers independently screened, assessed quality, and extracted data. Meta-analysis used Mantel-Haenszel method. RESULTS: Following full-text screening, 12 studies were deemed eligible for inclusion in the systematic review, encompassing a total of 42,592 patients. A heightened occurrence of PJI was observed among TJA patients with ASB in comparison to controls (OR [95%CI] = 3.47 [1.42-8.44]). However, microorganisms responsible for the PJIs differed from those identified in the urine cultures of ASB. Additionally, analyses indicate that preoperative antibiotic treatment for ASB does not significantly affect the subsequent risk of PJI (OR [95% CI] = 1.00 [0.42-2.39]). Unlike surgical site infection (SSI), which did not show a difference in the rate of occurrence between the two groups, TJA patients with ASB were more likely to experience superficial wound infection (OR [95%CI] = 3.81 [2.02-7.21]). CONCLUSION: This review and meta-analysis confirm that ASB correlate with heightened risks of PJI and superficial infection in TJA patients. However, no relationship was found between ASB and PJI microorganisms which raise doubts about the role of ASB microorganisms as the direct cause of infection following TJA.

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Background: Periprosthetic joint infection (PJI) following total knee arthroplasty is a serious complication lacking evidence-based diagnostic and treatment protocols, particularly in ruling out persisting infection before reimplantation. Methods: This retrospective analysis assessed the mid-term outcomes of 66 patients undergoing septic two-stage knee revision surgeries from 2007 to 2013, diagnosed as per the Musculoskeletal Infection Society criteria. After implant removal and antibiotic treatment, reimplantation decisions were based on either joint aspiration, blood counts, and clinical examination (group A) or an open biopsy (group B). Both groups underwent meticulous debridement and spacer exchange during the interim period. Results: Late re-infection occurred in 12.1% of all patients. In group A, 13.8% experienced late re-infection, with 14.3% in subgroup A1 and 13.3% in subgroup A2. In group B, 10% had a late re-infection. No significant difference in re-infection or complication rates was found between the groups. Conclusions: The study did not demonstrate the superiority of group B's approach of open biopsy over group A's joint aspiration, clinical examination, and blood counts in preventing re-infection or reducing complications.

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BACKGROUND: Periprosthetic joint infection (PJI) remains a major complication following total joint arthroplasties (TJA), significantly affecting patient outcomes and healthcare costs. Despite advances in diagnostic techniques, challenges persist in accurately diagnosing PJI, underscoring the need for effective point-of-care testing (POCT). METHODS: This review examines the current literature and latest developments in POCT for diagnosing PJI, focusing on biomarkers such as alpha-defensin, leukocyte esterase, calprotectin, and C-reactive protein (CRP). Criteria from various societies like the Musculoskeletal Infection Society, Infectious Diseases Society of America, and the International Consensus Meeting were compared to evaluate the effectiveness of these biomarkers in a point-of-care setting. RESULTS: POCT provides rapid results essential for the timely management of PJI, with alpha-defensin and leukocyte esterase showing high specificity and sensitivity. Recent advancements have introduced novel biomarkers like calprotectin, which demonstrate high diagnostic accuracy. However, challenges such as the variability in test performance and the need for validation under different clinical scenarios remain. DISCUSSION: While POCT for PJI shows promising results, their integration into clinical practice requires standardized protocols and further validation. The evolution of these diagnostic tools offers a potential shift toward more personalized and immediate care, potentially improving outcomes for patients undergoing TJA.

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BACKGROUND: Periprosthetic joint infection (PJI) continues to be one of the leading causes of failure following total hip arthroplasty (THA). The objectives of the study were to (1) determine the minimum 2-year infection-free survivorship of 2-stage revision THA, (2) determine the causative organisms for repeat 2-stage revision THA, and (3) characterize the results of failed 2-stage revisions and evaluate patient-reported outcome measures (PROMs). METHODS: A retrospective chart review was completed for patients who underwent 2-stage revision THA for PJI. Prospective data were collected on each patient, including demographics, causative organisms, complications, and type of reoperation. The PROMs, including Harris Hip Score, 12-item Short-Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained prior to 2-stage revision THA surgery and annually as part of standard clinical and radiographic follow-up. RESULTS: A total of 328 patients who underwent a 2-stage revision THA for a PJI were included in the study (mean age 67 years [range, 28 to 90], mean body mass index of 30.6 [range, 15 to 57]). The overall infection-free survivorship for 2-stage revision THA was 73.8% at a minimum of 2 years (range, 2 to 20). Overall, 194 (59.1%) patients who had successful infection eradication underwent a 2-revision THA only. The most common single organisms infected were Staphylococcus aureus (12.5%) and Staphylococcus epidermidis (11%). Higher reoperation rates were found in cases with methicillin-resistant Staphylococcus aureus and polymicrobial infections. All PROMs showed statistical improvement from preoperatively to the latest follow-up appointment. CONCLUSIONS: Two-stage revision THA is associated with a good success rate in the treatment of PJIs at mid-term to long-term follow-up. Polymicrobial and methicillin-resistant Staphylococcus aureus infections are poor prognostic factors, making the eradication of infection more difficult. The management of PJIs continues to be one of the most important orthopaedic challenges to treat.

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