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ObjectiveThe optimal duration of postsurgical antibiotic therapy for adult native joint bacterial arthritis remains unknown.MethodsWe conducted a prospective, unblinded, randomised, non-inferiority study comparing either 2 or 4 weeks of antibiotic therapy after surgical drainage of native joint bacterial arthritis in adults. Excluded were implant-related infections, episodes without surgical lavage and episodes with a follow-up of less than 2 months.ResultsWe enrolled 154 cases: 77 in the 4-week arm and 77 in the 2-week arm. Median length of intravenous antibiotic treatment was 1 and 2 days, respectively. The median number of surgical lavages was 1 in both arms. Recurrence of infection was noted in three patients (2%): 1 in the 2-week arm (99% cure rate) and 2 in the 4-week arm (97% cure rate). There was no difference in the number of adverse events or sequelae between the study arms. Of the overall 154 arthritis cases, 99 concerned the hand and wrist, for which an additional subgroup analysis was performed. In this per-protocol subanalysis, we noted three recurrences: one in the 2-week arm (97 % cure); two in the 4-week arm (96 % cure) and witnessed sequelae in 50% in the 2-week arm versus 55% in the 4-week arm, of which five (13%) and six (13%) needed further interventions.ConclusionsAfter initial surgical lavage for septic arthritis, 2 weeks of targeted antibiotic therapy is not inferior to 4 weeks regarding cure rate, adverse events or sequelae and leads to a significantly shorter hospital stay, at least for hand and wrist arthritis.Trial registration number NCT03615781.

Background Approximately 88,000 primary hip replacements are performed in England and Wales each year. Around 1% go on to develop deep prosthetic joint infection. Between one-stage and two-stage revision arthroplasty best treatment options remain unclear. Our aims were to characterise consultant orthopaedic surgeons’ decisions about performing either one-stage or two-stage revision surgery for patients with deep prosthetic infection (PJI) after hip arthroplasty, and to identify whether a randomised trial comparing one-stage with two-stage revision would be feasible. Methods Semi-structured interviews were conducted with 12 consultant surgeons who perform revision surgery for PJI after hip arthroplasty at 5 high-volume National Health Service (NHS) orthopaedic departments in England and Wales. Surgeons were interviewed before the development of a multicentre randomised controlled trial. Data were analysed using a thematic approach. Results There is no single standardised surgical intervention for the treatment of PJI. Surgeons balance multiple factors when choosing a surgical strategy which include multiple patient-related factors, their own knowledge and expertise, available infrastructure and the infecting organism. Surgeons questioned whether it was appropriate that the two-stage revision remained the best treatment, and some surgeons' willingness to consider more one-stage revisions had increased over recent years and were influenced by growing evidence showing equivalence between surgical techniques, and local observations of successful one-stage revisions. Custom-made articulating spacers was a practice that enabled uncertainty to be managed in the absence of definitive evidence about the superiority of one surgical technique over the other. Surgeons highlighted the need for research evidence to inform practice and thought that a randomised trial to compare treatments was needed. Most surgeons thought that patients who they treated would be eligible for trial participation in instances where there was uncertainty about the best treatment option. Conclusions Surgeons highlighted the need for evidence to support their choice of revision. Some surgeons' willingness to consider one-stage revision for infection had increased over time, largely influenced by evidence of successful one-stage revisions. Custom-made articulating spacers also enabled surgeons to manage uncertainty about the superiority of surgical techniques. Surgeons thought that a prospective randomised controlled trial comparing one-stage with two-stage joint replacement is needed and that randomisation would be feasible.

Background There is a concern regarding the use of a closed-suction drain (CSD) in two-stage exchange arthroplasty for periprosthetic joint infection as it may decrease the antibiotic concentrations in the joint fluids. The purpose of this study was to identify whether the use of a CSD could reduce local antibiotic concentrations following spacer implantation. Methods A prospective, randomized, controlled trial was conducted at our institution between January 2018 and November 2018. We enrolled 32 patients undergoing two-stage exchange arthroplasty for periprosthetic hip infection with an interim cement spacer containing 4-g vancomycin and 2-g meropenem per 40-g methyl-methacrylate cement polymer. Patients were randomized and evenly divided into the study group (non-CSD) and control group (CSD group) by sealed envelopes. Drainage samples of joint fluids ( n  = 160) were collected every 24 h for the first five days following spacer implantation. The antibiotic concentrations of drainage samples were measured by high-performance liquid chromatography, and the bioactivities of the drainage samples against methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA and MRSA) and E. coli were assessed. Results There was no significant difference in the decrease of vancomycin (study group vs. control group: 163.20 ± 77.05 vs. 162.39 ± 36.31; p  = 0.917) and meropenem concentration (123.78 ± 21.04 vs. 117.27 ± 19.38; P  = 0.548) between the two groups during the first five days following spacer implantation. All joint drainage samples in each group exhibited antibacterial activity against MSSA, MRSA and E. coli . Conclusions The use of CSD following the implantation of an antibiotic-loaded cement spacer does not reduce the effectiveness of such a spacer in two-stage exchange arthroplasty. (Chinese Clinical Trial Registry, ChiCTR-INR-17014162. Registered 26 December 2017.)

Background Although large series from national joint registries may accurately reflect indications for revision TKAs, they may lack the granularity to detect the true incidence and relative importance of such indications, especially periprosthetic joint infections (PJI). Questions/purposes Using a combination of individual chart review supplemented with New Zealand Joint Registry data, we asked: (1) What is the cumulative incidence of revision TKA? (2) What are the common indications for revising a contemporary primary TKA? (3) Do revision TKA indications differ at various followup times after primary TKA? Methods We identified 11,134 primary TKAs performed between 2000 and 2015 in three tertiary referral hospitals. The New Zealand Joint Registry and individual patient chart review were used to identify 357 patients undergoing subsequent revision surgery or any reoperation for PJI. All clinical records, radiographs, and laboratory results were reviewed to identify the primary revision reason. The cumulative incidence of each revision reason was calculated using a competing risk estimator. Results The cumulative incidence for revision TKA at 15 years followup was 6.1% (95% CI, 5.1%–7.1%). The two most-common revision reasons at 15 years followup were PJI followed by aseptic loosening. The risk of revision or reoperation for PJI was 2.0% (95% CI, 1.7%–2.3%) and aseptic loosening was 1.2% (95% CI, 0.7%–1.6%). Approximately half of the revision TKAs secondary to PJI occurred within 2 years of the index TKA (95% CI, 0.8%–1.2%), whereas half of the revision TKAs secondary to aseptic loosening occurred 8 years after the index TKA (95% CI, 0.4%–0.7%). Conclusions In this large cohort of patients with comprehensive followup of revision procedures, PJI was the dominant reason for failure during the first 15 years after primary TKA. Aseptic loosening became more important with longer followup. Efforts to improve outcome after primary TKA should focus on these areas, particularly prevention of PJI. Level of Evidence Level III, therapeutic study.

Purpose Total knee arthroplasty (TKA) rates have increased substantially in the recent decades worldwide, with Germany being one of the leading countries in the prevalence of TKA. The aim of this study was to provide an overview of treatment changes during the last decade and to project the expected burden of primary and revision TKA (rTKA) for the next 30 years. Methods Comprehensive nationwide data from Germany was used to quantify primary and revision TKA rates as a function of age and gender. Projections were performed with use of a Poisson regression models and a combination of exponential smoothing and autoregressive integrated moving average models on historical procedure rates in relation to official population projections from 2020 to 2050. Results The incidence rate of primary TKAs is projected to increase by around 43% to 299 per 100,000 inhabitants [95% CI 231–368], leading to a projected total number of 225,957 primary TKAs in 2050 (95% CI 178,804–276,442). This increase has been related to a growing number of TKA performed in male patients, with the highest increase modelled in patients between 50 and 65 years of age. At the same time, the annual total number of revision procedures is forecast to increase even more rapidly by almost 90%, accounting for 47,313 (95% CI 15,741–78,885; IR = 62.7 per 100,000, 95% CI 20.8–104.5) procedures by 2050. Those numbers are primarily associated with a rising number of rTKAs secondary to periprosthetic joint infection (PJI). Conclusions Using this country- specific forecast approach, a rising number of primary TKA and an even more rapidly growing number of rTKA, especially for PJI, has been projected until 2050, which will inevitably provide a huge challenge for the future health care system. As many other industrialized nations will face similar demographic and procedure-specific developments, these forecasts should be alarming for many health care systems worldwide and emphasize the tremendous need for an appropriate financial and human resource management in the future. Level of evidence Level III, prognostic study, economic and decision analysis.

Purpose Suppurative arthritis of the hip (SAH) in infants under six months of age is prone to misdiagnosis and missed diagnosis in clinical practice, leading to catastrophic outcomes. Our study aimed to investigate the clinical prognosis of SAH in children under six months of age. Method Children with SAH who underwent surgery at our hospitals between January 2010 and December 2019 were the subject of a retrospective analysis. We utilized Forlin’s classification and Bennett’s radiological grade to assess hip joint deformations in the last follow-up. Results A total of 13 children with SAH under 6 months of age were included, with an average age of 1.8 months (1–4 months). 11 patients were referred to our department due to \" absence of movement \" and only 3 cases (23.1%) involved fever (body temperature exceeding 38 °C). Two children were sent to our hospital for treatment after being misdiagnosed as DDH in other hospitals and treated unsuccessfully for with Pavlik braces. Delayed treatment for approximately 2 weeks. The mean follow-up duration was 3.1 years. Forlin’s classification system during the final follow-up assessment. The distribution of residual deformities was as follows: 1A7 cases, 1B2 cases, 2 A 4 cases, and 2B 0 cases. 4 hips underwent subsequent reconstruction surgery. Conclusion Early diagnosis can significantly reduce the adverse prognosis of SAH in children under 6 months of age, and hip ultrasound reports should not replace thorough physical examination. Understanding how to differentiate ultrasound images, prioritizing the integration of clinical extensive physical examination, and being aware of SAH are all required.

Background Bacterial (i.e., septic) arthritis requires prompt source control, including drainage of the infected synovial fluid, often through arthrocentesis (needle aspiration) or surgical intervention, in combination with antibiotics to prevent joint damage; however, when surgical intervention is required, conventional arthroscopy can lead to treatment delays and anesthesia-related complications. To overcome these delays, needle arthroscopy was recently developed to offer the possibility of 2-mm diameter arthroscopy lavage under local anesthesia. The purpose of this study was to prospectively evaluate bedside needle arthroscopy under local anesthesia to demonstrate its potential as an effective, minimally invasive alternative for timely diagnosis and joint lavage in patients with (suspected) native bacterial arthritis in a real-world clinical practice setting. Methods Over a 30-month period, this prospective, double center cohort study included patients with either confirmed (positive synovial fluid culture) or highly suspected (≥ 2 local signs and ≥ 1 systemic sign) native joint bacterial arthritis. The primary outcome was the need for reoperation (conventional arthroscopy or arthrotomy) within 30 days. Bivariate analysis assessed differences in patient and treatment characteristics between successful and failed needle arthroscopic debridement. Results Forty-two patients (44 native joints) underwent needle arthroscopy. The mean age was 67 years (SD 16), the mean BMI was 26.8 kg/m 2 (SD 3.9), and 69% were male. The knee ( n  = 34, 77%) was the most commonly involved joint. Within 30 days, 14% (6/44; 95% CI 5–27%) required a reoperation (conventional arthroscopy or arthrotomy). Two parameters were identified as risk factors for failure of a single debridement: the baseline level of ESR (112 mm/hr vs. 57 mm/hr, p  = 0.027) and purulent synovial fluid (67% vs. 11%; p  = 0.011). No serious procedure-related complications were observed. Conclusions A single bedside needle arthroscopy was effective in treating 86% of patients with confirmed or suspected native joint bacterial arthritis in a real-world practice, avoiding the need for general anesthesia or conventional surgery. This approach represents a safe and effective, minimally invasive alternative that can be rapidly implemented, enabling early joint lavage and potentially reducing the risk of secondary osteoarthritis. Trial registration We pre-registered this trial on the Dutch Trial Register, later called CCMO (NTR 21076, CCMO NL78387.018.21).

Background Pediatric septic arthritis requires immediate recognition, as delayed diagnosis can cause severe joint damage and long-term dysfunction. In the absence of guideline-based cut-off values for laboratory markers, surgical decisions are often made on a case-by-case basis. Due to the scarcity of evidence specific to the pediatric population, treatment strategies are often based on adult data, highlighting the need for targeted research in this population. To address this gap, we developed a diagnostic algorithm that incorporated reliable predictive factors. Methods Of 443 joint aspirations performed in our clinic (2014–2024), 132 (29.8%) were for suspected septic arthritis. After applying exclusion criteria, 80 cases were included. Clinical (fever, pain with movement, comorbidities), laboratory parameters at the time of joint aspiration (serum CRP, synovial white blood cell count [syWBC], serum white blood cell count [seWBC], synovial neutrophil perventage [syN%] and radiological data (radiographs, CT and MRI if available) were collected. Septic arthritis was defined by detection of pathogens in joint aspirate via culture or PCR. Results A pathogen was identified in 25% (20/80) of cases, with Kingella kingae (30%) being the most frequently detected organism, followed by Staphylococcus aureus (25%). Regression analysis revealed CRP ( p  < 0.01), syWBC ( p  = 0.04), but not syN% ( p  = 0.51) as predictors. ROC analysis yielded optimal cutoff values for CRP (69 mg/L; AUC = 0.82; 95% CI 0.71–0.93) and syWBC (65,000 cells/µL; AUC = 0.79; 95% CI 0.66–0.92). A diagnostic algorithm using CRP > 69 mg/L alone, or CRP < 69 mg/L combined with syWBC > 110,000 cells/µL, predicted septic arthritis with a sensitivity of 85% (95% CI 0.62–0.97; p  < 0.01) and a specificity of 90% (95% CI 0.79–0.96; p  < 0.01). Conclusion CRP was slightly more accurate than syWBC in predicting septic arthritis. When combined in an recursive partitioning model, these parameters demonstrated strong diagnostic performance. In cases where CRP measurements may be unreliable, an elevated syWBC count represents a CRP-independent alternative, although with reduced specificity. Level of evidence Level III: a retrospective case-control study

Introduction Septic arthritis of the knee is a serious condition that requires prompt surgical intervention to prevent irreversible joint damage and systemic complications. Incision and debridement is the standard treatment approach for managing knee septic arthritis. However, limited research exists on long-term trends in these surgical procedures. This study aims to analyse the trends in knee incision and debridement surgeries for septic arthritis in Sweden over a 16-year period (2008–2023), focusing on demographic variations and projections through 2030. Methods A retrospective, population-based study was conducted using data from the Swedish National Patient Register (NPR) for the period of January 1, 2008, to December 31, 2023. All patients aged ≥ 15 years who underwent knee incision and debridement surgery for septic arthritis were included. Demographic data were categorized by age, sex, and geographical region. Incidence rates were calculated per 100,000 inhabitants, and Poisson regression models were used to analyse temporal trends and project future surgical incidence rates through 2030. Results A total of 4,809 knee incision and debridement surgeries were performed between 2008 and 2023 in Sweden. Men accounted for 3,100 surgeries, compared to 1,709 for women. The highest number of surgeries occurred in 2023 ( n  = 404). The most affected age groups were 65–74 years (1,161 surgeries) and 75–84 years (1,127 surgeries). The overall incidence increased from 3.4 to 4.6 per 100,000 over the study period, with men consistently having higher rates. Significant regional variations were observed, with Jönköping, Jämtland, and Kalmar reporting the highest incidence rates. Projections suggest the incidence will continue to rise, reaching 4.6 per 100,000 by 2030. Conclusion The incidence of knee incision and debridement surgeries for septic arthritis in Sweden has steadily increased over the past 16 years, particularly among older adults and men. Significant regional disparities exist, highlighting the need for targeted interventions. Projections suggest that the burden of septic arthritis will continue to rise, necessitating enhanced preventive measures, early diagnosis, and resource planning to meet future healthcare needs.

Purpose Septic arthritis (SA) is a rare but significant clinical challenge in orthopedics that can impact patients’ quality of life. This study aims to examine the clinical outcomes of patients undergoing two-stage total joint replacement (TJR) in hip and knee SA and analyze potential predictors of treatment failure. Methods A retrospective analysis was conducted using data from a prospectively collected institutional arthroplasty registry from January 1st, 2012, to January 1st, 2019. Patients with hip or knee SA who underwent a two-stage TJR and had at least two years of follow-up were included. Demographic characteristics, surgical variables, and outcomes were collected and analyzed from clinical and surgical data. Statistical analysis was performed using IBM SPSS Statistics, with statistical significance at p  < 0.05. Results One hundred and fourteen patients (61 with hip SA, 53 with knee SA) were included in the study. The mean follow-up was 72.8 months. Postoperatively, both clinical and functional outcomes significantly improved, as indicated by the Hip Society Score (HHS) and Knee Society Score (KSS). The overall success rate of the two-stage protocol was 89.5%. Complications that did not require revision occurred in 21% of cases. The most identified pathogen was methicillin-sensitive Staphylococcus aureus (MSSA). Difficult-to-treat (DTT) infections and post-traumatic etiology were identified as predictors of treatment failure in patients undergoing two-stage TJR for hip and knee SA. Conclusions Two-stage TJR in hip and knee SA demonstrated favorable clinical outcomes at mid-term follow-up. The procedure significantly improved functional scores and achieved a high success rate, while DTT infections and post-traumatic etiology were associated with a higher risk of treatment failure.