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In primary shoulder arthroplasty (SA), intravenous (IV) cefazolin has demonstrated lower rates of infectious complications when compared to IV vancomycin. However, previous analyses included SA cohorts with both complete and incomplete vancomycin administration. Therefore, it is currently unclear whether cefazolin still maintains a prophylactic advantage to vancomycin when it is appropriately indicated and sufficiently administered at the time of surgical incision. This study evaluated the comparative efficacy of cefazolin and complete vancomycin administration for surgical prophylaxis in primary shoulder arthroplasty with respect to infectious complications. A retrospective cohort study was conducted utilizing a single institution total joint registry database, where all primary SA types (hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse shoulder arthroplasty) performed between 2000 to 2019 for elective and trauma indications using IV cefazolin or complete vancomycin administration as the primary antibiotic prophylaxis were identified. Vancomycin was primarily indicated for patients with a severe self-reported penicillin or cephalosporin allergy and/or MRSA colonization. Complete administration was defined as at least 30 minutes of antibiotic infusion prior to incision. All included SA had at least 2 years of clinical follow-up. Multivariable Cox proportional hazard regression was used to evaluate all-cause infectious complications including survival free of prosthetic joint infection (PJI). The final cohort included 7177 primary SA, 6879 (95.8%) received IV cefazolin and 298 (4.2%) received complete vancomycin administration. Infectious complications occurred in 120 (1.7%) SA leading to 81 (1.1%) infectious reoperations. Of the infectious complications, 41 (0.6%) were superficial infections and 79 were (1.1%) PJIs. When categorized by administered antibiotics, there were no differences in rates of all infectious complications (1.6% vs. 2.3%; P =.352), superficial complications (0.5% vs. 1.3%; P =.071), PJI (1.1% vs. 1.0%; P =.874), or infectious reoperations (1.1% vs. 1.0%; P =.839). On multivariable analyses, complete vancomycin infusion demonstrated no difference in rates of infectious complications compared to cefazolin administration (hazard ratio [HR], 1.50 [95% confidence interval (CI), 0.70 to 3.25]; P =.297), even when other independent predictors of PJI (male sex, prior surgery, and Methicillin-resistant Staphylococcus aureus colonization) were considered. In comparison to cefazolin, complete administration of vancomycin (infusion to incision time greater than 30 minutes) as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should promote appropriate indications for the use of cefazolin or vancomycin, and when necessary, ensure complete administration of vancomycin to mitigate additional infectious risks after primary SA. [ABSTRACT FROM AUTHOR]

Background: Non‐tuberculous mycobacteria (NTM) are rare causes of bone and joint infection (BJI) and there is limited evidence on which to base management decisions. This study describes 1 year of experience from a multi‐disciplinary BJI team which collects data on all cases reviewed at a tertiary referral centre in Queensland, Australia. Methods: The database was interrogated for all cases in which NTM were recovered from operative samples. Individual chart review was performed to collect the details of each case. Results: A total of seven cases were managed between 1st February 2021 and 28th February 2022, comprising one patient with chronic osteomyelitis, three with fracture‐related infections, two with prosthetic joint infections, and one with infection of a synthetic ligament graft. In contrast to pulmonary NTM infections, most patients were clinically well and immunocompetent, and most infections were propagated by direct inoculation. Time to diagnosis was unknown in three patients, with 1, 2, 2, and 5 months for the remaining four. Rapid growing NTM were diagnosed on routine cultures and specific mycobacterial cultures were confirmatory. Management was characterized by multiple stage surgical procedures and prolonged antimicrobial regimens. Conclusions: Antimicrobial complications were common; however, all patients were infection free at their latest follow up. Despite the inherent limitations, these results suggest that routinely ordering mycobacterial culture is of low yield. There is potential for shorter‐term oral antimicrobial treatments. Prospective research is required to optimize treatment regimens and durations. [ABSTRACT FROM AUTHOR]

Objectives Osteoarticular infection (OAI) is a feared complication of Staphylococcus aureus bacteraemia (SAB) and is associated with poor outcomes. We aimed to explore the risk of OAI and death following SAB in patients with and without rheumatoid arthritis (RA) and to identify risk factors for OAI in patients with RA. Methods Danish nationwide cohort study of all patients with microbiologically verified first-time SAB between 2006–18. We identified RA, SAB, comorbidities, and RA-related characteristics (e.g. orthopaedic implants and antirheumatic treatment) in national registries including the rheumatology registry DANBIO. We estimated the cumulative incidence of OAI and death and adjusted hazard ratios (HRs, multivariate Cox regression). Results We identified 18 274 patients with SAB (n  = 367 with RA). The 90-day cumulative incidence of OAI was 23.1% (95% CI 18.8; 27.6) for patients with RA and 12.5% (12.1; 13.0) for patients without RA (non-RA) [HR 1.93 (1.54; 2.41)]. For RA patients with orthopaedic implants cumulative incidence was 29.4% (22.9; 36.2) [HR 1.75 (1.08; 2.85)], and for current users of tumor necrosis factor inhibitors (TNFi) it was 41.9% (27.0; 56.1) [HR 2.27 (1.29; 3.98) compared with non-users]. All-cause 90-day mortality following SAB was similar in RA [35.4% (30.6; 40.3)] and non-RA [33.9% (33.2; 34.5), HR 1.04 (0.87; 1.24)]. Conclusion Following SAB, almost one in four patients with RA contracted OAI corresponding to a doubled risk compared with non-RA. In RA, orthopaedic implants and current TNFi use were associated with approximately doubled OAI risk. One in three died within 90 days in both RA and non-RA. These findings encourage vigilance in RA patients with SAB to avoid treatment delay of OAI. [ABSTRACT FROM AUTHOR]

Purpose of Review: Reverse shoulder arthroplasty (rTSA) is a commonly performed procedure to treat degenerative conditions of the shoulder. With its growing utilization, techniques to reliably diagnose and treat prosthetic joint infection (PJI) have become increasingly important. In this review we outline the current research and prevention methods of prosthetic joint infection in rTSA. This includes preoperative considerations, intraoperative, and postoperative treatment algorithms. Recent Findings: There is currently no established standardized protocol for preoperative infection prevention or post operative management. However, recent studies have identified risk factors for infection, as well as successful prevention techniques that can be implemented to minimize infection risk. Summary: Although there is no standardized protocol currently utilized to diagnose and treat shoulder PJI, we outline a potential set of preventative measures and postoperative management strategies that clinicians can use to properly diagnose and treat patients with this difficult condition. [ABSTRACT FROM AUTHOR]

Background: Prosthetic Joint Infection (PJI) is the most devastating complication of arthroplasty surgery and affects 1–5% of patients. Despite strict adherence to aseptic protocols and preventive measures, infection is the most common reason for revision arthroplasty, and the incidence is increasing. Treatment of PJI is challenging and often requires repeated major surgeries with sequentially poor results. The continued occurrence of PJI, and persistence after treatment, brings into question the current treatment paradigm. Preclinical evidence suggests a link between altered gut health and the risk of PJI in arthroplasty patients. Resistant starches helps to restore gut physiology by enhancing the beneficial microbiome and producing short-chain fatty acids, which have several health-conferring properties. The primary aim of this study is to investigate the effect of a commercially available prebiotic fibre formulation on the gut microbiome in PJI patients planned for a two-stage revision surgery. Methods: A double-blind placebo-controlled trial will assess the effect of 8-week supplementation of a commercially available prebiotic supplement in patients presenting with first-time PJI undergoing two-stage revision surgery. The supplementation phase will start after the first stage revision, and 80 patients will be randomised to receive either a test product (34 g of resistant starch) or a placebo (custard powder) daily for eight weeks. Stool and blood specimens will be collected at baseline, four weeks and eight weeks after the first-stage surgery and once at second-stage surgery. Gut microbiome profile, inflammatory cytokines and gut permeability biomarkers will be measured. Tissue specimens will be collected intra-operatively during first and second-stage surgeries. Baseline dietary patterns and gut symptoms will be recorded using validated questionnaires. Treatment outcomes will be reported for both cohorts using the Delphi criterion at one and two years after second-stage surgery. Discussion: This will be the first study to investigate the relationship between gut health optimisation and preventing PJI recurrence in arthroplasty patients. If supplementation with resistant starch improves gut health and reduces systemic inflammation, optimising the gut microbiome will be a recommended preoperative management strategy for arthroplasty patients. Trial registration no: ACTRN12623001273673. [ABSTRACT FROM AUTHOR]

Suppressive antibiotic therapy is prescribed when a patient has an infection that is presumed to be incurable by a defined course of therapy or source control. The cohort receiving suppressive antibiotic therapy is typically highly comorbid and the infections often involve retained prosthetic material. In part due to a lack of clear guidelines regarding the use of suppressive antibiotics, and in part due to the complex nature of the infections in question, patients are often prescribed suppressive antibiotics for extremely long, if not indefinite, courses. The risks of prolonged antibiotic exposure in this context are not fully characterized, but they include adverse drug effects ranging from mild to severe, the development of antibiotic-resistant organisms, and perturbations of the gastrointestinal microbiome. In this narrative review we present the available evidence for the use of suppressive antibiotic therapy in 4 common indications, examine the gaps in the current literature, and explore the known and potential risks of this therapy. We also make suggestions for improving the quality of evidence in future studies, particularly by highlighting the need for a standardized term to describe the use of long courses of antibiotics to suppress hard-to-treat infections. [ABSTRACT FROM AUTHOR]

Prosthetic joint infection (PJI) is a major complication following total arthroplasty. Rising antimicrobial resistance (AMR) to antibiotics will further increase therapeutic insufficiency. New antibacterial technologies are being developed to prevent PJI. In vivo models are still needed to bridge the translational gap to clinical implementation. Though rabbit models have been used most frequently, there is no consensus about methodology and measured outcomes. The PubMed, Scopus, and EMBASE databases were searched for literature on PJI in rabbit models. Data extraction included bias control, experimental design, and outcome measures of the NZW rabbit models in the articles. A total of 60 articles were included in this systematic literature review. The articles were divided into six groups based on the PJI intervention: no intervention used (21%), revision surgery (14%), prevention with only antibiotics (21%), prevention with surface modifications (7%), prevention with coatings (23%), and others (14%). Despite the current availability of guidelines and recommendations regarding experimental design, bias control, and outcome measures, many articles neglect to report on these matters. Ultimately, this analysis aims to assist researchers in determining suitable clinically relevant methodologies and outcome measures for in vivo PJI models using NZW rabbits to test new antimicrobial technologies. [ABSTRACT FROM AUTHOR]

Prosthetic joint infections caused by Campylobacter are uncommon, with the majority of cases being attributed to C. fetus. This case report represents the third instance of a prosthetic hip infection caused by C. coli following an episode of gastroenteritis and, notably, in an immunocompetent patient. The infection was successfully managed by surgical debridement and lavage with retention of the prosthesis and 12 weeks of antibiotics. Furthermore, we present the first whole-genome sequence of a Campylobacter strain responsible for prosthetic joint infection and offer a comprehensive review of the literature on such infections. [ABSTRACT FROM AUTHOR]

Background: Revision total elbow arthroplasty (rTEA) remains a technically challenging procedure with potential for substantial morbidity. Cases involving excessively long cement mantles, removal of well-fixed implants or infected revisions requiring complete cement removal introduce additional technical challenges. Our purpose was to describe the outcomes, results, and complications associated with the use of cortical windows in rTEA. In addition, we provide a technical description of the procedure. Methods: rTEA cases utilizing a cortical window performed by two surgeons between 2019 and 2023 were reviewed. Baseline demographics and case characteristics were recorded. Preoperative and postoperative outcomes were compared, including range of motion, radiographic outcomes, surgical complications and patient-reported outcome measures. Results: Seven rTEA cases involving either a humeral or ulnar cortical window were included with an average follow-up of 15 months. Indications for cortical windows included infection, periprosthetic humerus fracture and presumed aseptic loosening. Improvements were noted postoperatively for pain scores, Quick Disabilities of the Arm, Shoulder and Hand and Single Assessment Numeric Evaluation elbow scores. Final flexion-extension and pronation-supination were 100° and 156°. One patient (14%) had a postoperative complication (failure of fixation of a periprosthetic humerus fracture). There were no cases of intraoperative iatrogenic fracture or nerve injury. Conclusion: For rTEA cases during which a cortical window was performed, complications occurred infrequently in the short term. In these challenging procedures, cortical windows appear to provide a relatively safe and efficient means of removing excessively long cement mantles or well-fixed components.

Revision total elbow arthroplasty (rTEA) is a technically challenging procedure that is associated with high rates of surgical complications. Cement removal remains an important and difficult component of rTEA. Particularly in the case of prosthetic joint infection following TEA, failure to remove all of the cement from the index procedure results in higher rates of recurrent or persistent infection. Options for cement removal include the use of nonpowered instruments, powered instruments, ultrasonic devices, arthroscopic-assisted techniques, bone episiotomies, and cortical windows. Carefully assessing the risks and benefits of each of these techniques can provide aid in both improving surgical efficiency and potentially reducing surgical morbidity during these complex procedures. The purpose of this narrative review was to explore technical aspects of cement removal for well-fixed implants during rTEA.

Abstract Background Prosthetic Joint Infection (PJI) is the most devastating complication of arthroplasty surgery and affects 1–5% of patients. Despite strict adherence to aseptic protocols and preventive measures, infection is the most common reason for revision arthroplasty, and the incidence is increasing. Treatment of PJI is challenging and often requires repeated major surgeries with sequentially poor results. The continued occurrence of PJI, and persistence after treatment, brings into question the current treatment paradigm. Preclinical evidence suggests a link between altered gut health and the risk of PJI in arthroplasty patients. Resistant starches helps to restore gut physiology by enhancing the beneficial microbiome and producing short-chain fatty acids, which have several health-conferring properties. The primary aim of this study is to investigate the effect of a commercially available prebiotic fibre formulation on the gut microbiome in PJI patients planned for a two-stage revision surgery. Methods A double-blind placebo-controlled trial will assess the effect of 8-week supplementation of a commercially available prebiotic supplement in patients presenting with first-time PJI undergoing two-stage revision surgery. The supplementation phase will start after the first stage revision, and 80 patients will be randomised to receive either a test product (34 g of resistant starch) or a placebo (custard powder) daily for eight weeks. Stool and blood specimens will be collected at baseline, four weeks and eight weeks after the first-stage surgery and once at second-stage surgery. Gut microbiome profile, inflammatory cytokines and gut permeability biomarkers will be measured. Tissue specimens will be collected intra-operatively during first and second-stage surgeries. Baseline dietary patterns and gut symptoms will be recorded using validated questionnaires. Treatment outcomes will be reported for both cohorts using the Delphi criterion at one and two years after second-stage surgery. Discussion This will be the first study to investigate the relationship between gut health optimisation and preventing PJI recurrence in arthroplasty patients. If supplementation with resistant starch improves gut health and reduces systemic inflammation, optimising the gut microbiome will be a recommended preoperative management strategy for arthroplasty patients. Trial registration no ACTRN12623001273673.

Abstract Background Prosthetic joint infections (PJI) are recalcitrant, hard-to-treat infections and severe complications of joint arthroplasty. Therefore, there is a need to develop new effective treatment strategies, and animal models of high clinical relevance are needed. This study aimed to develop a detailed surgical protocol for hip hemiarthroplasty in Göttingen minipigs and a thorough post-mortem sampling protocol to pave the way for creating a minipig PJI model. Methods Three adult female Göttingen minipigs underwent surgery with insertion of a hip hemiarthroplasty, using the anterior approach to the hip joint. After surgery the minipigs were followed closely with daily clinical evaluation and gait scoring. Comprehensive post-mortem analyses were performed with evaluation of macroscopic lesions, microbiology, synovial fluid analysis and histology. Results The study resulted in the first Göttingen minipig with hip hemiarthroplasty and identified several points of awareness when inserting a hip prosthesis in minipigs, especially the high risk of joint dislocation. A spontaneous PJI occurred in one of the minipigs, revealing an impaired ability of the immune cells to reach the bacteria at the bone-prosthesis interface. Conclusion The present study provides a detailed description of surgical technique and post-mortem sampling and validates the suitability of the hip hemiarthroplasty minipig model for future experimental modeling of PJI.

Abstract Background Staphylococci cause a wide range of infections, including implant-associated infections which are difficult to treat due to the presence of biofilms. Whilst some proteins involved in biofilm formation are known, the differences in biofilm production between staphylococcal species remains understudied. Currently biofilm formation by Staphylococcus aureus is better understood than other members of the genus as more research has focused on this species. Results We assembled a panel of 385 non-aureus Staphylococcus isolates of 19 species from a combination of clinical sources and reference strains. We used a high-throughput crystal violet assay to assess the biofilm forming ability of all strains and assign distinct biofilm formation categories. We compared the prevalence of Pfam domains between the categories and used machine learning to identify amino acid 20-mers linked to biofilm formation. This identified some domains within proteins already linked to biofilm formation and important domains not previously linked to biofilm formation in staphylococci. RT-qPCR confirmed the expression of selected genes predicted to encode important domains within biofilms in Staphylococcus epidermidis. The prevalence and distribution of biofilm associated domains showed a link to phylogeny, suggesting different Staphylococcus species have independently evolved different mechanisms of biofilm production. Conclusions This work has identified different routes to biofilm formation in diverse species of Staphylococcus and suggests independent evolution of biofilm has occurred multiple times across the genus. Understanding the mechanisms of biofilm formation in any given species is likely to require detailed study of relevant strains and the ability to generalise across the genus may be limited.

Aims: This study aimed to evaluate the BioFire Joint Infection (JI) Panel in cases of hip and knee periprosthetic joint infection (PJI) where conventional microbiology is unclear, and to assess its role as a complementary intraoperative diagnostic tool. Methods: Five groups representing common microbiological scenarios in hip and knee revision arthroplasty were selected from our arthroplasty registry, prospectively maintained PJI databases, and biobank: 1) unexpected-negative cultures (UNCs), 2) unexpected-positive cultures (UPCs), 3) single-positive intraoperative cultures (SPCs), and 4) clearly septic and 5) aseptic cases. In total, 268 archived synovial fluid samples from 195 patients who underwent acute/chronic revision total hip or knee arthroplasty were included. Cases were classified according to the International Consensus Meeting 2018 criteria. JI panel evaluation of synovial fluid was performed, and the results were compared with cultures. Results: The JI panel detected microorganisms in 7/48 (14.5%) and 15/67 (22.4%) cases related to UNCs and SPCs, respectively, but not in cases of UPCs. The correlation between JI panel detection and infection classification criteria for early/late acute and chronic PJI was 46.6%, 73%, and 40%, respectively. Overall, the JI panel identified 12.6% additional microorganisms and three new species. The JI panel pathogen identification showed a sensitivity and specificity of 41.4% (95% confidence interval (CI) 33.7 to 49.5) and 91.1% (95% CI 84.7 to 94.9), respectively. In total, 19/195 (9.7%) could have been managed differently and more accurately upon JI panel evaluation. Conclusion: Despite its microbial limitation, JI panel demonstrated clinical usefulness by complementing the traditional methods based on multiple cultures, particularly in PJI with unclear microbiological results. Cite this article: Bone Joint Res 2024;13(7):353–361.

Currently, despite advancements in diagnostic and therapeutic modalities, osteomyelitis and prosthetic joint infection (PJI) continue to pose significant challenges for orthopaedic surgeons. These challenges are primarily attributed to the high degree of heterogeneity exhibited by these disorders, which are influenced by a combination of environmental and host factors. Recent research efforts have delved into the pathogenesis of osteomyelitis and PJI by investigating single nucleotide polymorphisms (SNPs). This review comprehensively summarizes the current evidence regarding the associations between SNPs and the predisposition to osteomyelitis and PJI across diverse populations. The findings suggest potential linkages between SNPs in genes such as IL-1, IL-6, IFN-γ, TNF-α, VDR, tPA, CTSG, COX-2, MMP1, SLC11A1, Bax, NOS2, and NLRP3 with the development of osteomyelitis. Furthermore, SNPs in genes like IL-1, IL-6, TNF-α, MBL, OPG, RANK, and GCSFR are implicated in susceptibility to PJI. However, it is noted that most of these studies are single-center reports, lacking in-depth mechanistic research. To gain a more profound understanding of the roles played by various SNPs in the development of osteomyelitis and PJI, future multi-center studies and fundamental investigations are deemed necessary. [ABSTRACT FROM AUTHOR]

The management of prosthetic joint infections is a complex and multilayered process that is additionally complicated by the formation of bacterial biofilm. Foreign material provides the ideal grounds for the development of an intricate matrix that hinders treatment and creates a difficult environment for antibiotics to act. Surgical intervention is often warranted but requires appropriate adjunctive therapy. Despite available guidelines, several aspects of antibiotic therapy with antibiofilm activity lack clear definition. Given the escalating challenges posed by antimicrobial resistance, extended treatment durations, and tolerance issues, it is essential to ensure that antimicrobials with antibiofilm activity are both potent and diverse. Evidence of biofilm-active drugs is highlighted, and alternatives to classical regimens are further discussed. [ABSTRACT FROM AUTHOR]

Background: Intraosseous regional administration (IORA) as a widely applicable and clinically valuable route of administration has gained significant attention in the context of total knee arthroplasty (TKA) for the prophylactic administration of antibiotics. However, there is still controversy regarding its effectiveness and safety. The latest meta-analysis reports that the use of IORA for antibiotics in TKA is as safe and effective as IV administration in preventing prosthetic joint infection (PJI), but they did not separate the statistics for primary TKA and revision TKA, which may be inappropriate. There is currently a lack of evidence specifically comparing the outcomes of prophylactic antibiotic administration via IORA or IV route in primary/revision TKA, respectively, and new research evidence has emerged. Purposes: In this study, we conducted a systematic review and meta-analysis with the primary objective of comparing the local drug tissue concentration and the incidence of PJI between preoperative IORA and intravenous (IV) administration of prophylactic antibiotics in TKA. Additionally, the occurrence of complications between the two administration routes was also compared. Patients and Methods: This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) guidelines. Retrospective cohort studies and prospective randomized controlled trials that utilized intraosseous local drug delivery for prophylactic antibiotics in knee arthroplasty were included. English literature from PubMed, Embase, and Cochrane Library databases was searched from the inception of each database until December 2023. Two researchers independently screened the literature, assessed the quality, and extracted data according to the inclusion criteria. The primary outcomes were local antibiotic tissue concentration and postoperative PJI incidence, while the secondary outcome was the occurrence of postoperative complications. Statistical analysis was performed using Review Manager 5.3 software. Results: This study included 7 prospective randomized controlled trials and 5 retrospective cohort studies. A total of 4091 patients participated in the 12 included studies, with 1,801 cases receiving IORA and 2,290 cases in the control group. In terms of local drug tissue concentration, intraosseous infusion (IO) 500 mg vancomycin significantly increased the drug concentration in the periarticular adipose tissue (SMD: 1.36; 95% CI: 0.87–1.84; P < 0.001; I2 = 0%) and bone tissue (SMD: 0.94; 95% CI: 0.49–1.40; P < 0.001; I2 = 0%) compared to IV 1 g vancomycin. Regarding the incidence of postoperative PJI after primary TKA, IO 500 mg vancomycin was more effective in reducing the occurrence of PJI compared to IV 1 g vancomycin (OR: 0.19; 95% CI: 0.06–0.59; P < 0.001; I2 = 36%). Finally, no significant differences were found between the two groups in terms of postoperative pulmonary embolism (PE) (OR: 1.72; 95% CI: 0.22–13.69; P = 0.59; I2 = 0%) and vancomycin-related complications (OR: 0.54; 95% CI: 0.25–1.19; P = 0.44; I2 = 0%). Conclusions: Preoperative prophylactic antibiotic administration via IORA in TKA significantly increases local drug tissue concentration without significantly increasing systemic drug-related complications compared to traditional IV administration. In primary TKA, low-dose vancomycin via IORA is more effective in reducing the incidence of PJI compared to traditional IV regimens. However, its effectiveness remains controversial in high-risk populations for PJI, such as obese, diabetic, and renal insufficiency patients, as well as in revision TKA. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infection (PJI) can be a serious complication of total knee arthroplasty (TKA). A method believed to decrease the incidence of PJI is antibiotic-laden bone cement (ALBC). Current clinical practice guidelines do not recommend ALBC in primary TKA. The purpose of this study was to compare ALBC to plain cement (PC) in preventing PJI in primary TKA. This retrospective analysis included 109,242 Medicare patients in the American Joint Replacement Registry who underwent a cemented primary TKA from January 2017 to March 2021, and had at least 1 year of follow-up. Patients who received ALBC were compared to patients who received PC. Demographic and case-specific variables such as age, sex, race, body mass index, Charlson Comorbidity Index, anesthesia type, and operative time were used to create propensity scores. A logistic regression was run to predict the probability of receiving ALBC. Also, a multivariate model was run on the full unstratified population, using the same covariates as were used to create the propensity model. The primary outcome was differences in PJI rates. Logistic regression analysis showed that a higher preoperative diagnosis of osteoarthritis, higher Charlson Comorbidity Index, higher body mass index, women, race, and anesthesia requirements increased a patient's probability of receiving ALBC. In the full unstratified multivariate model, ALBC did not show a statistically significant difference in risk of revision for infection compared to PC. The use of ALBC in primary TKA has not been shown to be more efficacious in preventing PJI within the population of Medicare patients in the United States. However, this study is limited given it is a retrospective database study that may inherently have biases and the large dataset has a potential for overpowering the findings. [ABSTRACT FROM AUTHOR]

The purpose of this retrospective analysis of a prospective quality control project was to determine whether the use of intrawound vancomycin powder (IVP) decreases the rate of periprosthetic joint infection (PJI) within 90 days following primary total hip arthroplasty (THA). From October 2021 to September 2022, a prospective quality control project was undertaken in which 10 high-volume THA surgeons alternated between using and not using IVP each month while keeping other perioperative protocols unchanged. A retrospective analysis of the project was performed to compare the group of patients who received IVP to the group of patients who did not. The primary outcome was a culture positive infection within 90 days following primary THA. Secondary outcomes included gram-positive culture, overall reoperation rate, wound complications, readmission, and wound complications within 90 days post-operatively. A total of 1,193 primary THA patients were identified for analysis. There were 523 (43.8%) patients who received IVP and were included in the IVP group, while 670 (56.2%) did not and were included in the non-IVP group. Age, body mass index, and sex were similar between the 2 groups (P >.25). The IVP group had a higher rate of culture positive joint infections (1.7 [0.8, 3.2] versus 0.3% [0.04, 1.1], P =.01) than the non-IVP group. All PJI's were found to have gram positive bacteria in both groups. The IVP group had a higher overall reoperation rate than the non-IVP group (6.1 [4.2, 8.5] versus 2.4% [1.4, 3.9], P <.01). The IVP group had a higher reoperation rate for any wound complication compared to non-IVP patients (2.7 [1.5, 4.5] versus 0.7% [0.2, 1.7], P <.01). The overall readmission rate (6.1 [4.2, 8.5] versus 2.8% [1.7, 4.4], P <.01), as well as readmission for suspected infection (2.1 [1.1, 3.7] versus 0.6% [0.02, 1.5], P =.03), were higher in the IVP group. The use of IVP in primary THA was associated with a higher rate of PJI, overall reoperation, reoperation for wound complications, and readmission in a prospective quality control project. Until future prospective randomized studies determine the safety and efficacy of IVP in THA conclusively, we advocate against its utilization. [ABSTRACT FROM AUTHOR]

Chlorhexidine gluconate (CHG) and povidone-iodine (PI) are commonly used to prevent prosthetic joint infection (PJI) during total joint replacement; however, their effective concentrations and impact on biofilms are not well defined. To determine: (1) the in-vitro minimum inhibitory concentration of CHG and PI against model PJI-causing organisms and clinical isolates; (2) their impact on biofilm formation; (3) whether there is a synergistic benefit to combining the two solutions; and (4) whether adding the antibiotic vancomycin impacts antiseptic activity. We measured in-vitro growth and biofilm formation of Staphylococcus epidermidis , meticillin-sensitive and meticillin-resistant Staphylococcus aureus , Escherichia coli , Pseudomonas aeruginosa and Candida albicans , as well as recent clinical isolates, in the presence of increasing concentrations of CHG and/or PI. Checkerboard assays were used to measure potential synergy of the solutions together and with vancomycin. CHG and PI inhibited growth and biofilm formation of all model organisms tested at concentrations of 0.0004% and 0.33% or lower, respectively; highly dilute concentrations paradoxically increased biofilm formation. The solutions did not synergize with one another and acted independently of vancomycin. CHG and PI are effective at lower concentrations than typically used, establishing baselines to support further clinical trials aimed at optimizing wound disinfection. There is no synergistic advantage to using both in combination. Vancomycin is effective at inhibiting the growth of S. epidermidis and S. aureus ; however, it stimulates P. aeruginosa biofilm production, suggesting in the rare case of P. aeruginosa PJI, it could exacerbate infection. [ABSTRACT FROM AUTHOR]

Periprosthetic joint infections (PJIs) continue to be a complication that plagues arthroplasty. Albumin is a surrogate marker for nutrition as well as chronic inflammation, and hypoalbuminemia increases the risk of complications in arthroplasty. Patients with PJI are at increased risk for malnutrition and complications. This study's objective was to analyze patients who underwent treatment of PJI following total hip arthroplasty and investigate the outcome with regards to albumin levels. Overall, 48 patients who underwent surgery for a total hip PJI at 1 institution were reviewed. Albumin and C-reactive protein were recorded preoperatively and 2 to 3 weeks postoperatively. Treatment failure was determined by further surgical treatment for PJI or repeat infection, as determined by Musculoskeletal Infection Society guidelines. A debridement, antibiotics, and implant retention procedure was performed in 39 patients, and explant with the placement of an antibiotic spacer was performed in 9. Preoperative mean albumin levels were significantly decreased in patients who failed to clear their infection compared to patients who remained infection-free (2.5 versus 3.3, P <.001). Postoperative albumin levels decreased in this same population (2.6 versus 3.8, P <.001). C-reactive protein was elevated in patients who failed to clear their infection preoperatively (19.9 versus 7.5, P <.001) and postoperatively (7.0 versus 1.7, P <.001). The average time to repeat surgical treatment for their PJI was 9 months Lower albumin levels are observed in patients with PJI who failed to remain infection-free after surgery. Albumin is a surrogate marker for nutrition, and low albumin is associated with poor immune function. Hypoalbuminemia is found with chronic inflammation as well as malnutrition. Nutritional reserves are diverted to the acute inflammatory response during an infection, which can lead to a deficient state. Further research may develop treatments to alter this modifiable risk factor. Level 4. [ABSTRACT FROM AUTHOR]

Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood. A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P <.05. A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P <.0001) with higher ASA scores (P <.0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P =.0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P =.0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts. Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible. [ABSTRACT FROM AUTHOR]

Synovial fluid analysis is important in diagnosing prosthetic joint infection (PJI). The rate of culture-positive PJI in patients who have a dry tap of a total hip arthroplasty (THA) is not well described. We reviewed all image-guided THA aspirations, performed from 2014 to 2021 at a single academic institution. Aspirations were categorized as successful (≥ 0.5 mL) or unsuccessful (< 0.5 mL, "dry tap"). We analyzed culture data on all repeat aspirations and revision surgeries performed within 90 days of the initial dry tap. We reviewed 275 consecutive attempted THA aspirations of which 100 (36.4%) resulted in a dry tap. The dry tap cohort had a significantly higher percentage of fluoroscopic-guided aspirations (64%) and fewer ultrasound-guided aspirations (36%) compared to the successful aspiration cohort (48.9% fluoroscopic, 53.1% ultrasound, P =.0061). Of the 100 patients who have dry taps, 48 underwent revision surgery within 90 days of the initial dry tap, and 15 resulted in 2 or more positive cultures. The rate of PJI defined by MusculoSkeletal Infection Society major criteria in the dry tap cohort was 16.0%. Attempted aspiration of a THA resulted in a dry tap 36.4% of the time. Of those patients who had a dry tap, 16.0% were subsequently found to have PJI based on MusculoSkeletal Infection Society major criteria. Therefore, a "dry tap" does not exclude the diagnosis of infection and should not be considered reassuring for the absence of PJI. [ABSTRACT FROM AUTHOR]

Sterile surgical helmet systems are frequently utilized in total knee arthroplasty procedures to protect the surgeon while maintaining a comfortable working environment. However, common helmet systems pressurize the space between the surgical gown and the surgeon's skin. In gowns with a back seam, this may allow contaminated skin particles to escape into the surgical field. By measuring bacterial colony-forming units (CFUs), this study sought to determine if occlusion of the open back seam reduced the risk of potential contamination. First, qualitative analysis depicting airflow variations between gown configurations was performed using the Schlieren Spherical Mirror imaging system. Each gown configuration consisted of a sterile surgical helmet and one of 3 gown configurations: a standard gown with rear-tied closure, a standard gown with a surgical vest, and a zippered Toga-style gown. Next, a surgeon then performed simulated surgical activities for 60 minutes within a 1.4 m3 isolation chamber with work surfaces and controllable filtered air exchanges. During each procedure, contaminated particles were collected on sets of agar settle plates positioned directly behind the surgeon. Upon completion, the agar plates were incubated in a biolab, and the number of bacterial and fungal CFUs was counted. The experimental procedure was repeated 12 times for each gown configuration, with sterilization of the chamber between runs. Contamination rates were expressed as CFUs/m2/h. The mean contamination rate measured with the standard gown was 331.7 ± 52.0 CFU/m2/h. After the addition of a surgical vest, this rate decreased by 45% to 182.2 ± 30.8 CFU/m2/h (P =.02). Similarly, with the Toga-style gown, contamination rates dropped by 49% to 170.5 ± 41.9 CFU/m2/h (P =.01). When used in conjunction with surgical helmet systems, conventional surgical gowns do not prevent potential contamination of the surgical field. We recommend that staff within the surgical field cover the back seam of standard gowns with a vest or don a zippered Toga-style gown. [ABSTRACT FROM AUTHOR]

Background: Staphylococci cause a wide range of infections, including implant-associated infections which are difficult to treat due to the presence of biofilms. Whilst some proteins involved in biofilm formation are known, the differences in biofilm production between staphylococcal species remains understudied. Currently biofilm formation by Staphylococcus aureus is better understood than other members of the genus as more research has focused on this species. Results: We assembled a panel of 385 non-aureus Staphylococcus isolates of 19 species from a combination of clinical sources and reference strains. We used a high-throughput crystal violet assay to assess the biofilm forming ability of all strains and assign distinct biofilm formation categories. We compared the prevalence of Pfam domains between the categories and used machine learning to identify amino acid 20-mers linked to biofilm formation. This identified some domains within proteins already linked to biofilm formation and important domains not previously linked to biofilm formation in staphylococci. RT-qPCR confirmed the expression of selected genes predicted to encode important domains within biofilms in Staphylococcus epidermidis. The prevalence and distribution of biofilm associated domains showed a link to phylogeny, suggesting different Staphylococcus species have independently evolved different mechanisms of biofilm production. Conclusions: This work has identified different routes to biofilm formation in diverse species of Staphylococcus and suggests independent evolution of biofilm has occurred multiple times across the genus. Understanding the mechanisms of biofilm formation in any given species is likely to require detailed study of relevant strains and the ability to generalise across the genus may be limited. [ABSTRACT FROM AUTHOR]

Background: Periprosthetic joint infections (PJI) are among the most morbid complications in total hip arthroplasty (THA). The ideal incubation time, however, for intraoperative cultures for PJI diagnosis remains unclear. As such, the aim of this study was to determine if any differences existed in culture-positive rates and organism detection between five-day and fourteen-day cultures. Methods: This retrospective cohort study consisted of THA cases diagnosed with PJI performed between May 2014 and May 2020 at a single tertiary-care institution. Analyses compared five-day and fourteen-day cultures and carried out a pre-specified subgroup analysis by organism and PJI type. Results: A total of 147 surgeries were performed in 101 patients (57.1% females), of which 65% (n = 98) obtained five-day cultures and 34% (n = 49) obtained fourteen-day cultures. The positive culture rate was 67.3% (n = 99) with Staphylococcus aureus being the most common pathogen identified (n = 41 specimens, 41.4%). The positive culture rate was not significantly different between groups (66.3% five-day, 69.4% fourteen-day, p = 0.852). Fourteen-day cultures had a significantly longer time-to-positive culture (5.0 days) than five-day cultures (3.0 days, p < 0.001), a higher rate of fungi (5.6% vs. 0%), and a lower rate of Gram-negatives (4.5% vs. 18.7%, p = 0.016). Conclusions: Fourteen-day cultures did not increase the positivity rate, had higher rates of slow-growth pathogens, and had a longer time-to-positivization than five-day cultures. Prolonged culture holds may provide more thorough organism detection for PJI without increasing the diagnostic culture yield. [ABSTRACT FROM AUTHOR]

Complex surgical site infections (SSIs) and revisions for these infectious complications following total knee and hip arthroplasties are associated with significant economic costs. To evaluate the cost of one-stage and two-stage revision; debridement, antibiotics and implant retention (DAIR); and DAIR with liner exchange for complex hip or knee SSIs in Alberta, Canada. The Alberta Health Services Infection Prevention and Control database was used to identify individuals aged ≥18 years from the two major urban centres in Alberta – Calgary and Edmonton – with complex hip or knee SSIs who underwent surgical intervention between 1st April 2012 and 31st March 2019. Micro-costing and gross costing methods were used to estimate 12- and 24-month costs following the initial hospital admission for arthroplasty. Subgroup, inverse Gaussian and gamma regression analyses were used to evaluate associations between cost and revision procedure, age, sex and comorbidities. In total, 382 patients with complex SSIs were identified, with a mean age of 66.1 years. DAIR and DAIR with liner exchange resulted in the lowest 12- and 24-month costs at $53,197 [95% confidence interval (CI) $38,006–68,388] and $57,340 (95% CI $48,576–66,105), respectively; two-stage revision was the costliest procedure. Most of the costs incurred (>98%) were accrued within the first 12 months following the initial procedure. Medical costs are highest in the 12 months following initial arthroplasty, and for two-stage revision procedures in hip and knee complex SSIs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Prosthetic joint infections (PJIs) can have disastrous consequences for patient health, including removal of the device, and placement of cemented implants is often required during surgery to eradicate PJIs. In translational research, in vivo models are widely used to assess the biocompatibility and antimicrobial efficacy of antimicrobial coatings and compounds. Here, we aim to utilize Galleria mellonella implant infection models to assess the antimicrobial activity of antibiotic-loaded bone cement (ALBC) implants. Therefore, we used commercially available bone cement loaded with either gentamicin alone (PALACOS R+G) or with a combination of gentamicin and vancomycin (COPAL G+V), compared to bone cement without antibiotics (PALACOS R). Firstly, the in vitro antimicrobial activity of ALBC was determined against Staphylococcus aureus. Next, the efficacy of ALBC implants was analyzed in both the G. mellonella hematogenous and early-stage biofilm implant infection model, by monitoring the survival of larvae over time. After 24 h, the number of bacteria on the implant surface and in the tissue was determined. Larvae receiving dual-loaded COPAL G+V implants showed higher survival rates compared to implants loaded with only gentamicin (PALACOS R+G) and the control implants without antibiotics (PALACOS R). In conclusion, G. mellonella larvae infection models with antibiotic-loaded bone cements are an excellent option to study (novel) antimicrobial approaches. [ABSTRACT FROM AUTHOR]

Implant-related infections may need suppressive antibiotic therapy (SAT). We describe a SAT strategy using dalbavancin with therapeutic drug monitoring (TDM). This is a retrospective bicentric study of patients with implant-related infection who received dalbavancin SAT between January 2021 and September 2023. Fifteen patients were included. Median number of injections was 4 (IQR: 2–7). Median time between two reinjections was 57 days (IQR 28–82). Dalbavancin plasma concentrations were above 4 mg/L for 97.9% of dosages (93/95) and above 8 mg/L for 85% (81/95). These results support the use of dalbavancin SAT for implant-related infections. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluates whether IBD patients are at increased risk of implant-related complications after THA. Materials and methods: A retrospective study from 01 January 2010 to 31 October 31 2020 using an administrative claims database was performed. IBD patients undergoing THA (n = 11,025), without corticosteroid treatment, were propensity score matched to controls in a 1:5 ratio (n = 55,121) based on age, sex, and the Charlson Comorbidity Index (CCI). Outcomes evaluated included periprosthetic fracture, aseptic loosening, prosthetic joint infection, and THA revision within 2 years of index procedure. Chi-square analyses were used to compare the matched cohorts. The association of IBD and implant-related complications was evaluated using logistical regression to calculate odds ratios (ORs), 95% confidence intervals (95% CIs), and p -values. A p- value < 0.001 was used as the significance threshold. Results: Patients with IBD had a greater incidence and odds of total implant complications (7.03% vs. 3.98%; OR 1.76; p < 0.001) compared with matched controls. IBD patients had significantly higher incidence and odds of developing periprosthetic fracture (0.50% vs. 0.20%; OR 2.46; p < 0.001), THA revisions (2.21% vs. 1.17%; OR 1.91; p < 0.001), aseptic loosening (1.45% vs. 0.84%; OR 1.75; p < 0.001), and prosthetic joint infection (2.87% vs. 1.77%; OR 1.64; p < 0.001). Conclusions: Patients with IBD who underwent primary THA had a significantly higher risk of implant-related complications compared to matched controls. Providers should use this study to appropriately assess post-complication risk factors for their patients with IBD. [ABSTRACT FROM AUTHOR]

Prosthetic joint infection (PJI) carries major morbidity and mortality as well as a complicated and lengthy treatment course. In patients who have high degrees of socioeconomic disadvantage, this may be a particularly devastating complication. Our study sought to evaluate the impact of socioeconomic deprivation on outcomes following treatment for PJI of the knee. We conducted a retrospective review of revision total knee arthroplasty (TKA) procedures performed for the treatment of initial PJI between 2008 and 2020 at a single tertiary care center in the United States. The Area Deprivation Index (ADI) was used to quantify socioeconomic deprivation. The primary outcome measure was presence of a functional knee joint at the time of most recent follow-up defined as TKA components or an articulating spacer. A total of 96 patients were included for analysis. The median follow-up duration was 26.5 months. There was no significant difference in the rate of treatment failure (P =.63). However, the proportion of patients who had a functional knee arthroplasty (in contrast to having undergone arthrodesis, amputation, or retention of a static spacer) declined significantly with increasing ADI index (81.8% for the least disadvantaged group, 58.7% for the middle group, 42.9% for the most disadvantaged group, P =.021). Patients who have a higher socioeconomic disadvantage as measured by ADI are less likely to maintain a functional knee arthroplasty following treatment for TKA PJI. These findings support continued efforts to improve access to care and optimize treatment plans for patients who have socioeconomic disadvantage. [ABSTRACT FROM AUTHOR]

Prosthetic joint infections (PJIs) after megaprosthesis implantation are associated with high rates of treatment failure and amputation. Our study analyzed PJI treatment success rates by surgical strategy and assessed risks of reinfection and amputation. We retrospectively analyzed the outcomes of patients diagnosed with PJI after undergoing megaprosthesis implantation for oncologic indications. The 2011 Musculoskeletal Infection Society criteria were used to define PJI. Reinfection, reoperation, and amputation for PJI recurrence were assessed. A total of 67 patients with megaprosthesis PJIs were included. There were fourteen patients who were treated with debridement, antibiotics, and implant retention (DAIR), 31 with DAIR plus (DAIR with modular component exchange and stem retention), and 21 with two-stage revisions. Kaplan-Meier estimates were used for survival analyses and Cox proportional hazards for risk factor analyses. The two-year reinfection-free survival was 25% for DAIR and 60% for DAIR plus or two-stage revision (P =.049). The five-year amputation-free survival was 84% for DAIR plus or two-stage revision, and 48% for DAIR (P =.13). Reinfection-free, reoperation-free, and amputation-free survival were similar between DAIR plus and two-stage revision at the 2- and 5-year marks. Body mass index ≥30 (hazard ratio [HR] = 2.65) and chronic kidney disease (HR = 11.53) were risk factors for reinfection. Treatment with DAIR plus or two-stage revision (HR = 0.44) was a protective factor against reinfection. A DAIR was associated with high rates of treatment failure and higher amputation rates than DAIR plus or 2-stage surgery. A DAIR plus was not inferior to 2-stage revision clearing a PJI and might be performed in patients who cannot withstand two-stage revision surgery. [ABSTRACT FROM AUTHOR]

Revision shoulder arthroplasty (RevSA) is a complex procedure that can result in various postoperative complications. However, the impact of hepatitis C virus (HCV) on postoperative complications after RevSA remains unclear because of limited and inconsistent evidence. This study aims (1) to investigate the incidence of postoperative complications in patients with HCV undergoing RevSA and (2) to evaluate the impact of HCV treatment on complication rates at different time points after the revision procedure, specifically at 90 days, 1 year, and 2 years. We queried a national, all-payer database to investigate recent trends in the use of RevSA among HCV patients to assess postoperative complication rates, including venous thromboembolism (VTE), wound complication, transfusion, and periprosthetic joint infection (PJI). Statistical analyses involved propensity score matching to create balanced cohorts and logistic regression to determine the relative risk of postoperative complications. Data were analyzed with SPSS software (version 24.0 for Windows). The study included patients who underwent partial or total RevSA procedures between January 1, 2010, and December 31, 2020. Patients were identified based on medical claims that included procedural codes for RevSA and associated diagnosis codes for PJI or insertion/removal of an antibiotic spacer. A Bonferroni correction was used because many tests were performed and statistical significance was set at P =.0125. The HCV cohort demonstrated higher PJI rates at 1-year (5.5% vs. 3.9%, P =.006) and 2-year follow-ups (6.7% vs. 4.6%, P =.006). However, no significant differences emerged in VTE and wound complication rates between the HCV and non-HCV cohorts. Comparing untreated and treated HCV patients, the former showed significantly higher PJI rates at 2 years (P =.010), whereas the treated group had significantly lower odds ratios for PJI. When comparing treated HCV patients with the non-HCV cohort, minimal differences were found in postoperative outcomes, indicating no significant difference in the risk of complications between the groups. Our study observed an association between HCV patients who received antiviral treatment prior to RevSA and a reduced incidence of PJI compared to untreated HCV patients. When comparing this group to the non-HCV controls, there was no significant difference in the incidence of PJI, suggesting a potential association between antiviral treatment and the observed risk patterns in HCV patients. Proper management of HCV-positive patients during RevSA is crucial for improving outcomes and reducing complications. [ABSTRACT FROM AUTHOR]

Prosthetic joint infection (PJI) risk continues to receive much attention given its associated morbidity and costs to patients and healthcare systems. It has been hypothesized that invasive colonoscopies may increase the risk of PJI. However, the decision to administer antibiotic prophylaxis lacks clinical guidance. In this study we aimed to compare PJI rates in patients undergoing colonoscopies with and without antibiotic prophylaxis against a control group, analyzing PJI occurrences at 90 days, 6 months, 9 months, and 1-year post-procedure and (2) assess the impact of antibiotic prophylaxis on PJI rates to inform clinical guidelines. We queried a national, all-payer database to identify all primary total knee arthroplasty procedures without prior history of PJI between January 2010 and October 2020 (n = 1.9 million). All patients who had a diagnosis of PJI within one year of index procedure were excluded. There were three cohorts identified: colonoscopy with biopsy without antibiotic prophylaxis; colonoscopy with biopsy with antibiotic prophylaxis; and a control of no prior colonoscopy. Both colonoscopy cohorts were slightly younger and had higher comorbidities than the controls. The PJI diagnoses were identified at four separate time intervals within one-year after colonoscopy: 90-days; 6-months; 9-months; and 1-year. Chi -square analyses with odds ratios (ORs) and 95% confidence intervals were conducted for PJI rates between groups at all time-points. Among all cohorts, no significant differences in PJI rates were found at 90-days (P = 0.459), 6-months (P = 0.608), 9-months (P = 0.598), and 1-year (P = 0.330). Similarly, direct comparison of both colonoscopy groups, with and without antibiotic prophylaxis, demonstrated no PJI rate differences at 90-day (P = 0.540), 6-months (P = 0.812), 9-months (P = 0.958), and 1-year (P = 0.207). Ranges of ORs between the colonoscopy cohorts were 1.07–1.43. Invasive colonoscopy does not increase the risk of PJI in patients who have pre-existing knee implants. Furthermore, antibiotic prophylaxis may not be warranted in patients undergoing colonoscopy who have a planned biopsy. [ABSTRACT FROM AUTHOR]

PURPOSE OF REVIEW: Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty. RECENT FINDINGS: The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

Background: Prosthetic Joint Infection (PJI) is a serious complication after total hip arthroplasty (THA). PJI is the most common reason for revision surgery on patients with arthroplasty, leading to prolonged hospitalization, repeated surgical intervention, and sometimes in definitive loss of the implant. Clostridium perfringens causing PJI is highly unusual. Case report: In this case, we describe the diagnostic and therapeutic challenges of a Clostridium perfringens Prosthetic Joint Infection following a total hip arthroplasty in an elderly woman. Conclusion: This case is unique because it is the first published PJI with C. perfringens, successfully treated by a one-stage infection revision combined with twelve weeks of antibiotics. Despite an extensive work up, a PJI or C. perfringens infection was not proven preoperatively. Perioperative tissue and sonication cultures were the cornerstone of the diagnosis. C. perfringens may be seen as an ‘easy to treat’ pathogen and successful treatment is possible with a one-stage infection revision and additional antibiotics for twelve weeks.

Background: A prosthetic joint infection is a devasting diagnosis and challenging condition to treat. The aim of this study is to outline the investigations, management and outcomes in a series of patients who presented to our institution with an iliopsoas abscess (IPA) in the setting of an infected, metal-on-metal (MoM), hip arthroplasty. Case details: Six patients with an IPA associated with an ipsilateral MoM presented over four years. Medical history, serum markers, trimodal imaging, aspirations and surgical procedures performed were analysed The management algorithm employed is outlined.Five were diagnosed with culture positive prosthetic joint infections (PJI). Four patients had elevated Cobalt and Chromium levels and all patients had characteristic aseptic lymphocytic vasculitis (ALVAL) associated lesions on Magnetic Resonance Imaging. Four proceeded to two stage revision. One patient opted for lifelong antibiotic suppression therapy. Four patients who opted for revision surgery had an infection free survival at mean 6 years. Conclusions: Our case series describes a rare, but significant consideration in the practice of the modern arthroplasty surgeon and a successful management strategy to treat these cases. Surgeons should be mindful of the potential concurrent presence of a PJI in cases of an IPA in the context of a total hip replacement, but especially for MoM, where concomitant malignancy, ALVAL, and metallosis are frequently implicated.

Background: Polyurethane tibial and acetabular inserts that release high concentrations of antibiotics were used with debridement and implant retention to treat prosthetic joint infections. The hypothesis was that a low-friction, antibiotic-releasing bearing could provide a simpler, safer, and more patient-accepted treatment for infection using antibiotic cement and intravenous antibiotics. Methods: Patients (n = 106) with culture-positive infections received antibiotic inserts. Vancomycin and tobramycin were mixed into the polyurethane polymer at 7% by weight. Contraindications to debridement antibiotics and implant retention were a sinus tract, loose prostheses, and/or the wound could not be closed. Measurable outcomes were success in controlling infection, complications, patient acceptable symptomatic state, and need for revision surgery. Antibiotic levels were measured in joint fluid and blood; laboratory mechanical wear tests were performed; and results were compared to bone cement and polyethylene containing antibiotics. Results: Antibiotic-infused spacers sustained joint fluid antibiotic levels 8-12 times the therapeutic level and produced low serum levels with no toxicities. Mechanical testing showed low wear and retained mechanical integrity. All patients achieved complication-free remission of infection at a follow-up of 5-26 years. All patients had Harris hip and Knee Society scores above 85, and 68% achieved patient acceptable symptomatic state. Conclusions: All patients achieved remission of infection, fewer complications compared to revision using antibiotic bone cement, no antibiotic toxicity or adverse drug reactions, and 68% achieved patient acceptance. The antibiotic polyurethane inserts provided antibacterial efficacy comparable with currently used bone cement spacers, and their wear rate was approximately 20 times lower than bone cement as an articulation.

Coccidioidomycosis is a fungal infection endemic to certain regions of the Americas. In some cases, the organism may infect the musculoskeletal system, resulting in a prosthetic joint infection (PJI). Due to its difficulty in diagnosis, treatment of coccidioidomycosis in PJI is often delayed. Furthermore, with limited number of case reports, a standard of care in treatment has yet to be established. We present 2 cases of coccidioidomycosis PJI, the extensive evaluation that led to the diagnosis, and the treatment provided. This report highlights the natural progression of coccidioidomycosis in a prosthetic joint, the diagnostic features including histology, advanced imaging, and final treatment administered.

Abstract Total joint arthroplasty is the recommended treatment for patients with end-stage osteoarthritis, as it reduces disability and pain and restores joint function. However, prosthetic joint infection is a serious complication of this procedure, with the two-stage exchange being the most common treatment method. While there is consensus on diagnosing prosthetic joint infection, there is a lack of agreement on the parameters that can guide the surgeon in performing definitive reimplantation in a two-stage procedure. One approach that has been suggested to improve the accuracy of microbiologic investigations before definitive reimplantation is to observe a holiday period from antibiotic therapy to improve the accuracy of cultures from periprosthetic tissues, but these cultures report some degree of aspecificity. Therefore, several pieces of evidence highlight that performing reimplantation using continuous antibiotic therapy should be considered a safe and effective approach, leading to higher cure rates and a shorter period of disability. Dosage of C-reactive protein (CRP), erythrocyte sedimentation rate (ERS) and D-dimer are helpful in diagnosing prosthetic joint infection, but only D-dimer has shown sufficient accuracy in predicting the risk of infection recurrence after a two-stage procedure. Synovial fluid analysis before reimplantation has been shown to be the most accurate in predicting recurrence, and new cutoff values for leukocyte count and neutrophil percentage have shown a useful predictive rule to identify patients at risk of unfavourable outcome. A new scoring system based on a numerical score calculated from the beta coefficient derived through multivariate analysis of D-dimer levels, synovial fluid leukocytes and relative neutrophils percentage has demonstrated high accuracy when it comes to guiding the second step of two-stage procedure. In conclusion, reimplantation may be a suitable option for patients who are on continuous therapy without local symptoms, and with CRP and ERS within the normal range, with low synovial fluid leukocytes (

Abstract Introduction Fungal prosthetic joint infections comprise less than 1% of prosthetic joint infections. Thus, little is known regarding optimal management. This study aims to characterize the microbiology, surgical and medical management, and outcomes for these complex infections. The objectives of this study were to assess the impact of surgical approach, antifungal treatment, fungal species, and time to onset of infection from initial surgery on patient outcomes. Methods A retrospective record review over 12 years was performed in two health systems that included patients with a deep culture positive for a fungal isolate and the presence of a prosthetic joint. A literature review was performed using the same inclusion criteria. A total of 289 cases were identified and analyzed. Results Candida was the most common isolate, and a two-stage revision was the most commonly employed surgical modality. The type of surgical intervention had a statistically significant relationship with outcome (P = 0.022). Conclusions Two-stage revision with extended antifungal therapy is preferred in these infections due to higher rates of positive outcomes.

Bacterial biofilms on orthopedic implants are resistant to the host immune response and to traditional systemic antibiotics. Novel therapies are needed to improve patient outcomes. TRL1068 is a human monoclonal antibody (mAb) against a biofilm anchoring protein. For assessment of this agent in an orthopedic implant infection model, efficacy was measured by reduction in bacterial burden of Staphylococcus aureus, the most common pathogen for prosthetic joint infections (PJI). Systemic treatment with the biofilm disrupting mAb TRL1068 in conjunction with vancomycin eradicated S. aureus from steel pins implanted in the spine for 26 of 27 mice, significantly more than for vancomycin alone. The mechanism of action was elucidated by two microscopy studies. First, TRL1068 was localized to biofilm using a fluorescent antibody tag. Second, a qualitative effect on biofilm structure was observed using scanning electron microscopy (SEM) to examine steel pins that had been treated in vivo. SEM images of implants retrieved from control mice showed abundant three-dimensional biofilms, whereas those from mice treated with TRL1068 did not. Clinical Significance: TRL1068 binds at high affinity to S. aureus biofilms, thereby disrupting the three-dimensional structure and significantly reducing implant CFUs in a well-characterized orthopedic model for which prior tested agents have shown only partial efficacy. TRL1068 represents a promising systemic treatment for orthopedic implant infection.

Numerous studies have suggested that intra‐articular administration of antibiotics following primary revision surgery may be one of the methods for treating prosthetic joint infection (PJI). Vancomycin and meropenem are the two most commonly used antibiotics for local application. Determining the concentrations of vancomycin and meropenem in the serum and synovial fluid of patients with PJI plays a significant role in further optimizing local medication schemes and effectively eradicating biofilm infections. This study aimed to establish a rapid, sensitive, and accurate ultra‐performance liquid chromatography–tandem mass spectrometry (UPLC–MS/MS) method for determining the concentrations of vancomycin and meropenem in human serum and synovial fluid. Serum samples were processed using acetonitrile precipitation of proteins and dichloromethane extraction, while synovial fluid samples were diluted before analysis. Chromatographic separation was achieved in 6 min on a Waters Acquity UPLC BEH C18 column, with the mobile phase consisting of 0.1% formic acid in water (solvent A) and acetonitrile (solvent B). Quantification was carried out using a Waters XEVO TQD triple quadrupole mass spectrometer with an electrospray ionization (ESI) source in positive ion mode. The multiple reaction monitoring (MRM) mode was employed to detect the following quantifier ion transitions: 717.95–99.97 (norvancomycin), 725.90–100.04 (vancomycin), 384.16–67.99 (meropenem). The method validation conformed to the guidelines of the FDA and the Chinese Pharmacopoeia. The method demonstrated good linearity within the range of 0.5–50 μg/ml for serum and 0.5–100 μg/ml for synovial fluid. Selectivity, intra‐day and inter‐day precision and accuracy, extraction recovery, matrix effect, and stability validation results all met the required standards. This method has been successfully applied in the pharmacokinetic/pharmacodynamic (PK/PD) studies of patients with PJI. [ABSTRACT FROM AUTHOR]

Aseptic humeral stem loosening is an uncommon complication of shoulder arthroplasty, and its presence has been considered a highly specific predictor of prosthetic joint infection (PJI). Literature on aseptic humeral stem loosening is sparse. The primary purpose of this study was to determine the rate of aseptic humeral loosening in revision shoulder arthroplasty. Secondarily, we sought to identify predictors of septic and aseptic humeral loosening. Our institutional revision shoulder arthroplasty database was reviewed. Inclusion criteria were patients with humeral stem loosening as indicated in the operative report. Patient demographics, index surgery and indication, revision surgery and indication, and operative data were recorded. Charts were manually reviewed, and PJI scores were calculated using the International Consensus Meeting scoring criteria. International Consensus Meeting classifications of PJI "unlikely" and "possible" were considered aseptic, and PJI "probable" and "definite" were considered septic. Statistical analysis was performed to determine associations between the abovementioned variables and aseptic humeral loosening. Forty-six patients with 48 shoulders were included in our analysis. Ten cases (21%) were classified as definite PJI, 13 cases (27%) were classified as probable PJI, 4 cases (8%) were classified as possible PJI, and 21 cases (44%) were classified as PJI unlikely. On analysis of stem design, there were no statistically significant associations with aseptic loosening; although, a lack of proximal porous ingrowth surface trended toward higher rates of aseptic loosening in all patients and in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) subgroup analyses. In the index RTSA subgroup, aseptic loosening was associated with female sex (P =.005). Seventeen of 39 shoulders (44%) that underwent either index ATSA or RTSA demonstrated concomitant glenoid loosening. The absence of glenoid loosening was associated with aseptic humeral loosening in index ATSA and RTSA (P <.001). Fifty-two % of revision shoulder arthroplasty cases with humeral loosening performed at our institution were aseptic. There appear to be distinct demographic and radiographic factors that are more commonly associated with aseptic as opposed to septic humeral loosening. Our data demonstrate that demographic predictors of aseptic loosening of RTSA include female sex. The absence of glenoid component loosening is associated with aseptic humeral loosening and concomitant glenoid loosening is associated with septic humeral loosening. Understanding of these factors can guide the preoperative index of suspicion for PJI in the setting of humeral stem loosening. [ABSTRACT FROM AUTHOR]