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Background Revision for prosthetic joint infection (PJI) has a major effect on patients’ health but it remains unclear if early PJI after primary THA is associated with a high mortality. Questions/Purposes (1) Do patients with a revision for PJI within 1 year of primary THA have increased mortality compared with patients who do not undergo revision for any reason within 1 year of primary THA? (2) Do patients who undergo a revision for PJI within 1 year of primary THA have an increased mortality risk compared with patients who undergo an aseptic revision? (3) Are there particular bacteria among patients with PJI that are associated with an increased risk of death? Methods This population-based cohort study was based on the longitudinally maintained Danish Hip Arthroplasty Register on primary THA performed in Denmark from 2005 to 2014. Data from the Danish Hip Arthroplasty Register were linked to microbiology databases, the National Register of Patients, and the Civil Registration System to obtain data on microbiology, comorbidity, and vital status on all patients. Because reporting to the register is compulsory for all public and private hospitals in Denmark, the completeness of registration is 98% for primary THA and 92% for revisions (2016 annual report). The mortality risk for the patients who underwent revision for PJI within 1 year from implantation of primary THA was compared with (1) the mortality risk for patients who did not undergo revision for any reason within 1 year of primary THA; and (2) the mortality risk for patients who underwent an aseptic revision. A total of 68,504 primary THAs in 59,954 patients were identified, of those 445 primary THAs underwent revision for PJI, 1350 primary THAs underwent revision for other causes and the remaining 66,709 primary THAs did not undergo revision. Patients were followed from implantation of primary THA until death or 1 year of followup, or, in case of a revision, 1 year from the date of revision. Results Within 1 year of primary THA, 8% (95% CI, 6%–11%) of patients who underwent revision for PJI died. The adjusted relative mortality risk for patients with revision for PJI was 2.18 (95% CI, 1.54–3.08) compared with the patients who did not undergo revision for any cause (p < 0.001). The adjusted relative mortality risk for patients with revisions for PJI compared with patients with aseptic revision was 1.87 (95% CI, 1.11–3.15; p = 0.019). Patients with enterococci-infected THA had a 3.10 (95% CI, 1.66–5.81) higher mortality risk than patients infected with other bacteria (p < 0.001). Conclusions Revision for PJI within 1 year after primary THA induces an increased mortality risk during the first year after the revision surgery. This study should incentivize further studies on prevention of PJI and on risk to patients with the perspective to reduce mortality in patients who have had THA in general and for patients with PJI specifically. Level of Evidence Level III, therapeutic study.

The appropriate duration of antimicrobial therapy for bacterial prosthetic joint infection is debated. In this open-label, randomized, controlled, noninferiority trial involving 410 patients with prosthetic joint infection at 28 centers across France, antimicrobial therapy for 6 weeks was compared with therapy for 12 weeks and was not found to be noninferior.

The risk of prosthetic joint infection (PJI) is influenced by patient, surgical, and health-care factors. Existing evidence is based on short-term follow-up. It does not differentiate between factors associated with early onset caused by the primary intervention from those associated with later onset more likely to result from haematogenous spread. We aimed to assess the overall and time-specific associations of these factors with the risk of revision due to PJI after primary total hip replacement. We did a prospective observational cohort study analysing 623 253 primary hip procedures performed between April 1, 2003, and Dec 31, 2013, in England and Wales and recorded the number of procedures revised because of PJI. We investigated the associations between risk factors and risk of revision for PJI across the overall follow-up period using Poisson multilevel models. We reinvestigated the associations by post-operative time periods (0–3 months, 3–6 months, 6–12 months, 12–24 months, >24 months) using piece-wise exponential multilevel models with period-specific effects. Data were obtained from the National Joint Registry linked to the Hospital Episode Statistics data. 2705 primary procedures were subsequently revised for an indication of PJI between 2003 and 2014, after a median (IQR) follow up of 4·6 years (2·6–7·0). Among the factors associated with an increased revision due to PJI there were male sex (1462 [1·2‰] of 1 237 170 male-years vs 1243 [0·7‰] of 1 849 691 female-years; rate ratio [RR] 1·7 [95% CI 1·6–1·8]), younger age (739 [1·1‰] of 688 000 person-years <60 years vs 242 [0·6‰] of 387 049 person-years ≥80 years; 0·7 [0·6–0·8]), elevated body-mass index (BMI; 941 [1·8‰] 517 278 person-years with a BMI ≥30 kg/m2vs 272 [0·9‰] of 297 686 person-years with a BMI <25 kg/m2; 1·9 [1·7–2·2]), diabetes (245 [1·4‰] 178 381 person-years with diabetes vs 2120 [1·0‰] of 2 209 507 person-years without diabetes; 1·4 [1·2–1·5]), dementia (5 [10·1‰] of 497 person-years with dementia at 3 months vs 311 [2·6‰] of 120 850 person-years without dementia; 3·8 [1·2–7·8]), previous septic arthritis (22 [7·2‰] of 3055 person-years with previous infection vs 2683 [0·9‰] of 3 083 806 person-years without previous infection; 6·7 [4·2–9·8]), fractured neck of femur (66 [1·5‰] of 43 378 person-years operated for a fractured neck of femur vs 2639 [0·9‰] of 3 043 483 person-years without a fractured neck of femur; 1·8 [1·4–2·3]); and use of the lateral surgical approach (1334 [1·0‰] of 1 399 287 person-years for lateral vs 1242 [0·8 ‰] of 1 565 913 person-years for posterior; 1·3 [1·2–1·4]). Use of ceramic rather than metal bearings was associated with a decreased risk of revision for PJI (94 [0·4‰] of 239 512 person-years with ceramic-on-ceramic bearings vs 602 [0·5‰] of 1 114 239 peron-years with metal-on-polyethylene bearings at ≥24 months; RR 0·6 [0·4–0·7]; and 82 [0·4‰] of 190 884 person-years with ceramic-on-polyethyene bearings vs metal-on-polyethylene bearings at ≥24 months; 0·7 [0·5–0·9]). Most of these factors had time-specific effects. The risk of revision for PJI was marginally or not influenced by the grade of the operating surgeon, the absence of a consultant surgeon during surgey, and the volume of procedures performed by hospital or surgeon. Several modifiable and non-modifiable factors are associated with the risk of revision for PJI after primary hip replacement. Identification of modifiable factors, use of targeted interventions, and beneficial modulation of some of these factors could be effective in reducing the incidence of PJI. It is important for clinicians to consider non-modifiable factors and factors that exhibit time-specific effects on the risk of PJI to counsel patients appropriately preoperatively. National Institute for Health Research.

Background Reconstruction of periacetabular defects after pelvic tumor resection ranks among the most challenging procedures in orthopaedic oncology, and reconstructive techniques are generally associated with dissatisfying mechanical and nonmechanical complication rates. In an attempt to reduce the risk of dislocation, aseptic loosening, and infection, we introduced the LUMiC ® prosthesis (implantcast, Buxtehude, Germany) in 2008. The LUMiC ® prosthesis is a modular device, built of a separate stem (hydroxyapatite-coated uncemented or cemented) and acetabular cup. The stem and cup are available in different sizes (the latter of which is also available with silver coating for infection prevention) and are equipped with sawteeth at the junction to allow for rotational adjustment of cup position after implantation of the stem. Whether this implant indeed is durable at short-term followup has not been evaluated. Questions/purposes (1) What proportion of patients experience mechanical complications and what are the associated risk factors of periacetabular reconstruction with the LUMiC ® after pelvic tumor resection? (2) What proportion of patients experience nonmechanical complications and what are the associated risk factors of periacetabular reconstruction with the LUMiC ® after pelvic tumor resection? (3) What is the cumulative incidence of implant failure at 2 and 5 years and what are the mechanisms of reconstruction failure? (4) What is the functional outcome as assessed by Musculoskeletal Tumor Society (MSTS) score at final followup? Methods We performed a retrospective chart review of every patient in whom a LUMiC ® prosthesis was used to reconstruct a periacetabular defect after internal hemipelvectomy for a pelvic tumor from July 2008 to June 2014 in eight centers of orthopaedic oncology with a minimum followup of 24 months. Forty-seven patients (26 men [55%]) with a mean age of 50 years (range, 12–78 years) were included. At review, 32 patients (68%) were alive. The reverse Kaplan-Meier method was used to calculate median followup, which was equal to 3.9 years (95% confidence interval [CI], 3.4–4.3). During the period under study, our general indications for using this implant were reconstruction of periacetabular defects after pelvic tumor resections in which the medial ilium adjacent to the sacroiliac joint was preserved; alternative treatments included hip transposition and saddle or custom-made prostheses in some of the contributing centers; these were generally used when the medial ilium was involved in the tumorous process or if the LUMiC ® was not yet available in the specific country at that time. Conventional chondrosarcoma was the predominant diagnosis (n = 22 [47%]); five patients (11%) had osseous metastases of a distant carcinoma and three (6%) had multiple myeloma. Uncemented fixation (n = 43 [91%]) was preferred. Dual-mobility cups (n = 24 [51%]) were mainly used in case of a higher presumed risk of dislocation in the early period of our study; later, dual-mobility cups became the standard for the majority of the reconstructions. Silver-coated acetabular cups were used in 29 reconstructions (62%); because only the largest cup size was available with silver coating, its use depended on the cup size that was chosen. We used a competing risk model to estimate the cumulative incidence of implant failure. Results Six patients (13%) had a single dislocation; four (9%) had recurrent dislocations. The risk of dislocation was lower in reconstructions with a dual-mobility cup (one of 24 [4%]) than in those without (nine of 23 [39%]) (hazard ratio, 0.11; 95% CI, 0.01–0.89; p = 0.038). Three patients (6%; one with a preceding structural allograft reconstruction, one with poor initial fixation as a result of an intraoperative fracture, and one with a cemented stem) had loosening and underwent revision. Infections occurred in 13 reconstructions (28%). Median duration of surgery was 6.5 hours (range, 4.0–13.6 hours) for patients with an infection and 5.3 hours (range, 2.8–9.9 hours) for those without (p = 0.060); blood loss was 2.3 L (range, 0.8–8.2 L) for patients with an infection and 1.5 L (range, 0.4–3.8 L) for those without (p = 0.039). The cumulative incidences of implant failure at 2 and 5 years were 2.1% (95% CI, 0–6.3) and 17.3% (95% CI, 0.7–33.9) for mechanical reasons and 6.4% (95% CI, 0–13.4) and 9.2% (95% CI, 0.5–17.9) for infection, respectively. Reasons for reconstruction failure were instability (n = 1 [2%]), loosening (n = 3 [6%]), and infection (n = 4 [9%]). Mean MSTS functional outcome score at followup was 70% (range, 33%–93%). Conclusions At short-term followup, the LUMiC ® prosthesis demonstrated a low frequency of mechanical complications and failure when used to reconstruct the acetabulum in patients who underwent major pelvic tumor resections, and we believe this is a useful reconstruction for periacetabular resections for tumor or failed prior reconstructions. Still, infection and dislocation are relatively common after these complex reconstructions. Dual-mobility articulation in our experience is associated with a lower risk of dislocation. Future, larger studies will need to further control for factors such as dual-mobility articulation and silver coating. We will continue to follow our patients over the longer term to ascertain the role of this implant in this setting. Level of Evidence Level IV, therapeutic study.

Background The diagnosis of periprosthetic joint infection (PJI) remains a serious clinical challenge. There is a pressing need for improved diagnostic testing methods; biomarkers offer one potentially promising approach. Questions/purposes We evaluated the diagnostic characteristics of 16 promising synovial fluid biomarkers for the diagnosis of PJI. Methods Synovial fluid was collected from 95 patients meeting the inclusion criteria of this prospective diagnostic study. All patients were being evaluated for a revision hip or knee arthroplasty, including patients with systemic inflammatory disease and those already receiving antibiotic treatment. The Musculoskeletal Infection Society (MSIS) definition was used to classify 29 PJIs and 66 aseptic joints. Synovial fluid samples were tested by immunoassay for 16 biomarkers optimized for use in synovial fluid. Sensitivity, specificity, and receiver operating characteristic curve analysis were performed to assess for diagnostic performance. Results Five biomarkers, including human α-defensin 1-3, neutrophil elastase 2, bactericidal/permeability-increasing protein, neutrophil gelatinase-associated lipocalin, and lactoferrin, correctly predicted the MSIS classification of all patients in this study, with 100% sensitivity and specificity for the diagnosis of PJI. An additional eight biomarkers demonstrated excellent diagnostic strength, with an area under the curve of greater than 0.9. Conclusions Synovial fluid biomarkers exhibit a high accuracy in diagnosing PJI, even when including patients with systemic inflammatory disease and those receiving antibiotic treatment. Considering that these biomarkers match the results of the more complex MSIS definition of PJI, we believe that synovial fluid biomarkers can be a valuable addition to the methods utilized for the diagnosis of infection. Level of Evidence Level II, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.

Background Periprosthetic infection after total hip arthroplasty (THA) is a devastating complication. Reported rates of infection control range from 80% to 95% but mortality rates associated with treatment of infected THA are also substantial and we suspect underreported. Questions/Purposes For patients selected for two-stage treatment of infected THA we therefore determined (1) mortality; (2) rate of reimplantation; and (3) rate of reinfection. Methods We identified 202 patients (205 hips) with infected primary or revision THA treated with a two-stage protocol between 1996 and 2009 in our prospectively collected practice registry. Patients underwent two-stage treatment for infection, including removal of all implants and foreign material with implantation of an antibiotic-laden cement spacer in the first stage followed by intravenous culture-specific antibiotics for a minimum of 6 weeks. Second-stage reimplantation was performed if erythrocyte sedimentation rate and C-reactive protein were trending toward normal and the wound was well healed. Thirteen patients (13 hips) were lost to followup before 24 months. The minimum followup in surviving patients was 24 months or failure (average, 53 months; range, 24–180 months). Results Fourteen patients (7%; 14 hips) died before reimplantation and two were not candidates because of medical comorbidities. The 90-day mortality rate after the first-stage débridement was 4% (eight patients). Of the 186 patients (189 hips) who underwent reimplantation, 157 (83%) achieved control of the infection. Including all patients who underwent the first stage, survival and infection control after two-stage reimplantation was 76%. Conclusion Two-stage treatment of deep infection in primary and revision THA is associated with substantial mortality and a substantial failure rate from both reinfection and inability to perform the second stage. Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hip osteoarthritis is the most common joint disorder, and is represented by a degenerative process, resulting in pain and functional impairment. If conservative treatment for hip osteoarthritis fails, the only remaining option is hip arthroplasty. Despite good survival of implants, loosening of components is the most common complication. This leads to revision surgeries, which are technically demanding, expensive, and result in a low satisfaction rate. Uncemented hip replacements require proper osseointegration for increased survival. Physical characteristics of implants include biocompatibility, Young’s modulus of elasticity, strength, and corrosion resistance, and each influence fixation of implants. Moreover, implant surface treatments, pore size, pore density, and femoral stem design should be appropriately selected. Patients’ optimization of obesity, osteoporosis, cardiovascular disease, psychotic disorders, and smoking cessation are associated with a higher survival of implants. Surgical factors, such as approach, drilling and rasping, acetabular bone coverage, acetabular cup positioning, and implant size, also affect survival of implants. Avoiding drugs, which may impair osseointegration of implants, and having an appropriate rehabilitation protocol are important. Future directions include anabolic and anti-catabolic bone-acting drugs to enhance osseointegration of implants. Comprehensive knowledge of the factors mentioned above is important for preventing aseptic loosening, with important socioeconomic consequences.

The two-stage revision strategy has been claimed as being the \"gold standard\" for treating prosthetic joint infection. The one-stage revision strategy remains an attractive alternative option; however, its effectiveness in comparison to the two-stage strategy remains uncertain. To compare the effectiveness of one- and two-stage revision strategies in treating prosthetic hip infection, using re-infection as an outcome. Systematic review and meta-analysis. MEDLINE, EMBASE, Web of Science, Cochrane Library, manual search of bibliographies to March 2015, and email contact with investigators. Cohort studies (prospective or retrospective) conducted in generally unselected patients with prosthetic hip infection treated exclusively by one- or two-stage revision and with re-infection outcomes reported within two years of revision. No clinical trials were identified. Data were extracted by two independent investigators and a consensus was reached with involvement of a third. Rates of re-infection from 38 one-stage studies (2,536 participants) and 60 two-stage studies (3,288 participants) were aggregated using random-effect models after arcsine transformation, and were grouped by study and population level characteristics. In one-stage studies, the rate (95% confidence intervals) of re-infection was 8.2% (6.0-10.8). The corresponding re-infection rate after two-stage revision was 7.9% (6.2-9.7). Re-infection rates remained generally similar when grouped by several study and population level characteristics. There was no strong evidence of publication bias among contributing studies. Evidence from aggregate published data suggest similar re-infection rates after one- or two-stage revision among unselected patients. More detailed analyses under a broader range of circumstances and exploration of other sources of heterogeneity will require collaborative pooling of individual participant data. PROSPERO 2015: CRD42015016559.

Current techniques for the identification of the infecting organism in prosthetic-joint (e.g., hip or knee) infection remain insensitive. In this study of 331 surgeries involving prosthetic joint replacement, a new technique that sonicates the removed artificial joint is found to be more sensitive in identifying the infecting organism than are standard culture techniques. In surgeries involving prosthetic joint replacement, a new technique that sonicates the removed artificial joint is found to be more sensitive in identifying the infecting organism than are standard culture techniques. In the United States, 638,000 patients underwent hip or knee replacement in 2003. 1 Although they may improve the quality of life, these procedures are associated with complications, including aseptic failure and prosthetic-joint infection. 2 It is important to distinguish prosthetic-joint infection from other causes of joint failure, because its management is different. 3 Nonmicrobiologic methods developed for diagnosing native-joint infection use different criteria from those used to diagnose prosthetic-joint infection. 4 Microbiologic diagnosis of prosthetic-joint infection may also require different criteria from those used for the microbiologic diagnosis of native-joint infection. Most clinicians and laboratory workers culture periprosthetic tissue (hereafter referred to as . . .

Background A key issue in the treatment of periprosthetic joint infection (PJI) is the correct diagnosis. The main problem is lack of diagnostic tools able to diagnose a PJI with high accuracy. Alpha-defensin has been proposed as a possible solution, but in the current literature, there is a lack of independent validation. Questions/purposes We performed a prospective study to determine (1) what is the sensitivity, specificity, and positive and the negative predictive values of the alpha-defensin immunoassay test in diagnosing PJI; and (2) which clinical features may be responsible for false-positive and false-negative results? Methods Preoperative aspiration was performed in all patients presenting with a painful hip/knee arthroplasty, including both primary and revision implants. Metallosis, other inflammatory comorbidities, and previous/concomitant antibiotic therapy were not considered as exclusion criteria. An inadequate amount of synovial fluid for culture was an exclusion criterion. A total of 156 patients (65 knees, 91 hips) were included in this prospective study. At the time of revision, synovial fluid samples were taken to perform the alpha-defensin assay. During surgical débridement of tissue, samples for cultures and histologic evaluation were taken, and samples were cultured until positive or until negative at 14 days. A diagnosis of PJI was confirmed in 29 patients according to the International Consensus Group on PJI. Results The sensitivity of the alpha-defensin immunoassay was 97% (95% confidence interval [CI], 92%–99%), the specificity was 97% (95% CI, 92%–99%), the positive predictive value was 88% (95% CI, 81%–92%), and the negative predictive value was 99% (95% CI, 96%–99%). Among four false-positive patients, two had metallosis and one had polyethylene wear. The false-negative case presented with a draining sinus, and intraoperative cultures were also negative. Conclusions Alpha-defensin assay appears to be a reliable test, but followup evaluation is needed to estimate longer term performance of the test. The authors believe that alpha-defensin has demonstrated itself to be sufficiently robust that PJI diagnostic criteria now should include this test. Future studies are needed to compare the differences among the diagnostic capability of the available tests, in particular when metallosis is present, because metallosis may predispose the test to a false-positive result. Level of Evidence Level I, diagnostic study.