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Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients.A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance.The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis.Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The direct anterior approach (DAA) in total hip arthroplasty is of significant interest to both patients and surgeons, largely due to intense marketing. This study addressed the question, "What is the level of promotion of DAA total hip arthroplasty on the internet by American Association of Hip and Knee Surgeons (AAHKS) members?"An internet search was performed to identify surgeon-specific websites for each member of the AAHKS using the members' full name and a previously published set of criteria. Each website was evaluated utilizing a questionnaire to systematically identify claims made regarding proposed DAA-specific risks, benefits, as well as the presence/absence of supporting data.We identified 1855 qualified websites. The DAA was referenced on 22.8% (423/1855) of these websites. Claims regarding DAA-specific benefits included less invasive/muscle sparing (46.3%), quicker recovery (45.2%), decreased pain (28.1%), decreased hospital stay (22.0%), and decreased dislocation risk (16.3%). Potential DAA risks including lateral femoral cutaneous nerve injury, periprosthetic/greater trochanteric fracture, and wound complication/hematoma were addressed on only 4.7%, 3.1%, and 1.7% of websites, respectively. Supporting peer-reviewed literature was identified on only 3.6% of DAA websites.Over one-fifth of AAHKS members promoted the DAA on the internet. Member websites claimed DAA benefits such as faster recovery and decreased pain approximately 9 times more frequently than any potential risk of the procedure (P.001). While AAHKS policy does not regulate member marketing, it is the responsibility of all orthopedic surgeons to disseminate accurate, validated information concerning the procedures we perform.

Purpose Whilst medial UKR is indicated for full-thickness cartilage loss (FTCL) on occasion it has been used to treat partial-thickness cartilage loss (PTCL). This matched case-control study investigates the five-year outcomes in a consecutive series of UKR implanted for PTCL. Methods Between 2002 and 2014, 94consecutive UKR (90patients) were implanted by two surgeons for PTCL and followed up independently for a mean 6years (range 1-13). These cases were matched 1:2 based on age, gender and preoperative OKS with knees with FTCL anteromedial osteoarthritis managed with UKR. Functional outcomes, implant survival and incidence of reoperations was assessed at one, two and five years. A sub-study of 36knees (36patients) with PTCL who had had pre-operative MRI was performed to identify whether there were any MRI factors that predicted outcomes. Results Knees with PTCL had significantly worse functional outcomes (OKS and AKSS-O) at one, two and five years postoperatively. A quarter of knees with PTCL reported fair or poor results and a fifth failed to achieve a clinically significant improvement from baseline of four points or more on the OKS, double that seen in knees with FTCL. Whilst no difference in implant survival was detected between groups, knees with PTCL had a triple the reoperation rate with the majority, three-quarters, being arthroscopies for persistent pain. Patients with PTCL who achieved fair or poor outcomes were younger with worse preoperative functional scores, compared to those who achieve good or excellent outcomes however no other differences in baseline demographics were seen. MRI findings (FTCL, subchondral oedema, synovitis or effusion) did not provide additional prognostic information. Conclusion Medial UKR should be reserved for patients with FTCL, whilst some patients with PTCL do achieve good results, at present, we cannot identify which these will be and in this situation MRI is not only unhelpful but also misleading.

AimsWhile medial unicompartmental knee arthroplasty (UKA) is indicated for patients with full-thickness cartilage loss, it is occasionally used to treat those with partial-thickness loss. The aim of this study was to investigate the five-year outcomes in a consecutive series of UKAs used in patients with partial thickness cartilage loss in the medial compartment of the knee.Patients and MethodsBetween 2002 and 2014, 94 consecutive UKAs were undertaken in 90 patients with partial thickness cartilage loss and followed up independently for a mean of six years (1 to 13). These patients had partial thickness cartilage loss either on both femur and tibia (13 knees), or on either the femur or the tibia, with full thickness loss on the other surface of the joint (18 and 63 knees respectively). Using propensity score analysis, these patients were matched 1:2 based on age, gender and pre-operative Oxford Knee Score (OKS) with knees with full thickness loss on both the femur and tibia. The functional outcomes, implant survival and incidence of re-operations were assessed at one, two and five years post-operatively. A subgroup of 36 knees in 36 patients with partial thickness cartilage loss, who had pre-operative MRI scans, was assessed to identify whether there were any factors identified on MRI that predicted the outcome.ResultsKnees with partial thickness cartilage loss had significantly worse functional outcomes at one, two and five years post-operatively compared with those with full thickness loss. A quarter of knees with partial thickness loss had a fair or poor result and a fifth failed to achieve a clinically significant improvement in OKS from a baseline of four points or more; double that seen in knees with full thickness loss. Whilst there was no difference in implant survival between the groups, the rate of re-operation in knees with partial thickness loss was three times higher. Most of the re-operations (three-quarters), were arthroscopies for persistent pain. Compared with those achieving good or excellent outcomes, patients with partial thickness cartilage loss who achieved fair or poor outcomes were younger and had worse pre-operative functional scores. However, there were no other differences in the baseline demographics. MRI findings of full thickness cartilage loss, subchondral oedema, synovitis or effusion did not provide additional prognostic information.ConclusionMedial UKA should be reserved for patients with full thickness cartilage loss on both the femur and tibia. Whilst some patients with partial thickness loss achieve a good result we cannot currently identify which these will be and in this situation MRI is unhelpful and misleading. Cite this article: Bone Joint J 2017;99-B:475–82.