The Choice of Antibiotic Prophylaxis Influences the Infection Reoperation Rate in Primary Shoulder Arthroplasty: Analysis From the Swedish Shoulder Arthroplasty Register.

BACKGROUND: Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacteriumacnes , benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection. QUESTIONS/PURPOSES: After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin? METHODS: Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been estimated that more than 90% of all primary shoulder arthroplasties and shoulder reoperations are reported to the register. The age of the study population ranged between 16 and 98 years; the mean age at the primary surgery was 70 ± 10 years for the entire cohort, with a mean age of 67 ± 10 years and 72 ± 9 years for men and women, respectively. The mean observation period was 989 ± 669 days. From 2013 to 2019, there was a clear change in prophylaxis; in particular, the use of the combination of benzylpenicillin and cloxacillin increased dramatically and the use of cloxacillin alone decreased. Clindamycin prophylaxis increased moderately. The primary study endpoint was reported reoperation for infection. In the register, this is defined as repeat procedures of any kind, including biopsy, lavage of the joint, or revision, defined as secondary surgery in which a component was exchanged, removed, or added. To compare the reoperation rate in relation to the different antibiotics used, which changed over time, we controlled for age, gender, previous surgery, cement fixation, and arthroplasty type using a Cox proportional hazards model. RESULTS: When adjusting for age, gender, previous surgery, cement fixation, and arthroplasty type, cloxacillin prophylaxis was associated with an increased relative risk of reoperation for infection compared with the combination of cloxacillin and benzylpenicillin (hazard ratio [HR] 2.40 [95% confidence interval (CI) 1.35 to 4.25]; p = 0.003) and compared with clindamycin alone (HR 1.78 [95% CI 1.11 to 2.85]; p = 0.02). No difference was found between the cloxacillin and benzylpenicillin combination and clindamycin (HR 0.74 [95% CI 0.42 to 1.32]; p = 0.31). CONCLUSION: Our results indicate that prophylaxis against C. acnes may be warranted in shoulder arthroplasty. Because the absolute number of infections was low and infections could have been underreported to the register, our results should be interpreted with caution. There is no available information about the causative microorganisms. The study lays the groundwork for further investigations of antibiotic prophylaxis regimens in shoulder arthroplasty. Because large randomized controlled trials would be impractical to perform, prospective register-based randomized controlled studies might be a viable method. LEVEL OF EVIDENCE: Level Ⅲ, therapeutic study.

[Surgical Outcomes of Prosthetic Valve Endocarditis].

Prosthetic valve endocarditis is a fatal complication after valve replacement surgery. Early surgical intervention is recommended for patients who suffer from complications such as heart failure, valve dysfunction, and abscesses. In the present study, we evaluated the clinical characteristics of 18 patients who underwent surgery for prosthetic valve endocarditis at our institution between December 1990 and August 2022, and examined the appropriateness of the timing and method of surgery, and whether there was improvement in cardiac function. Guidelines-based surgical intervention resulted in improved survival and improved cardiac function in the early and late postoperative period.

Leadless pacemaker implantation after lead extraction for cardiac implanted electronic device infection.

BACKGROUND: Cardiac implanted electronic device (CIED) pocket and systemic infection remain common complications with traditional CIEDs and are associated with high morbidity and mortality. Leadless pacemakers may be an attractive pacing alternative for many patients following complete hardware removal for a CIED infection by eliminating surgical pocket-related complications as well as lower risk of recurrent complications. OBJECTIVE: To describe use and outcomes associated with leadless pacemaker implantation following extraction of a CIED system due to infection. METHODS: Patient characteristics and postprocedural outcomes were described in patients who underwent leadless pacemaker implantation at Duke University Hospital between November 11, 2014 and November 18, 2019, following CIED infection and device extraction. Outcomes of interest included procedural complications, pacemaker syndrome, need for system revision, and recurrent infection. RESULTS: Among 39 patients, the mean age was 71 ± 17 years, 31% were women, and the most frequent primary pacing indication was complete heart block (64.1%) with 9 (23.1%) patients being pacemaker dependent at the time of Micra implantation. The primary organism implicated in the CIED infection was Staphylococcus aureus (43.6%). Nine of the 39 patients had a leadless pacemaker implanted before or on the same day as their extraction procedure, and the remaining 30 patients had a leadless pacemaker implanted after their extraction procedure. During follow-up (mean 24.8 ± 14.7 months) after leadless pacemaker implantation, there were a total of 3 major complications: 1 groin hematoma, 1 femoral arteriovenous fistula, and 1 case of pacemaker syndrome. No patients had evidence of recurrent CIED infection after leadless pacemaker implantation. CONCLUSIONS: Despite a prior CIED infection and an elevated risk of recurrent infection, there was no evidence of CIED infection with a mean follow up of over 2 years following leadless pacemaker implantation at or after CIED system removal. Larger studies with longer follow-up are required to determine if there is a long-term advantage to implanting a leadless pacemaker versus a traditional pacemaker following temporary pacing when needed during the periextraction period in patients with a prior CIED infection.

Endoleak Complicated by communicating psoas abscess and aorto-enteric fistula in an immunocompromised patient.

PURPOSE: While endovascular repair of aortic aneurysm (EVAR) has become the mainstay treatment for abdominal aortic aneurysm (AAA), it is not without its disadvantages. Feared complications include graft infections, fistulation and endoleak, the outcomes of which may be life limiting. CASE REPORT: We present a case of a 57 year-old patient with human immunodeficiency virus (HIV) previously treated with EVAR for AAA complicated by endoleak post treatment. He developed an aorto-psoas abscess 2 years later which harboured Mycobacterium avium complex, and medical therapy was unsuccessful. He eventually underwent an extra-anatomical bypass and graft explant, for which an aortoenteric fistula was also discovered and repaired. CONCLUSION: Infection of endografts post EVAR is relatively rare, and there are presently no guidelines concerning its management. The concomittance of aorto-psoas abscess and aortoenteric fistula is even more uncommon, and necessitated surgical explant for source control purposes in our patient. Lifelong surveillance is required for complications of the aortic stump and bypass patency.

Efficacy of 2-stage revision using a prosthesis of antibiotic-loaded acrylic cement spacer with or without cortical strut allograft in infected total elbow arthroplasty.

PURPOSE: We aimed to evaluate the efficacy of a self-manufactured prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) spacer with or without cortical strut allograft in infected total elbow arthroplasty. METHODS: Between March 2009 and February 2018, we enrolled 18 patients (mean age, 66.9 years) who underwent 2-stage revision arthroplasty for prosthetic infection following total elbow arthroplasty. After implant removal in the first stage, we performed débridement and PROSTALAC insertion. During the second stage, we performed reimplantation using a cortical strut allograft for patients with a considerably severe bone defect. The mean follow-up period was 34 months (range, 25-60 months), during which we evaluated the Mayo Elbow Performance Score (MEPS), range of motion (ROM), and blood markers. RESULTS: In all 18 patients, infection control was ensured using intravenous (IV) antibiotic therapy for 6 weeks or IV antibiotics for 4 weeks converting to oral antibiotics for 2 weeks following PROSTALAC insertion. The mean visual analog scale score improved from 8 points preoperatively to 2 points postoperatively, and the mean MEPS improved from 32 points preoperatively to 82 points postoperatively (P < .05). The average ROMs at the last follow-up were 9° to 132° from extension to flexion, respectively. Two patients experienced ulnar nerve neuropraxia after surgery, from which they were resolved. Moreover, 2 and 4 patients developed superficial wound infection and triceps insufficiency, respectively, and there was no infection recurrence. CONCLUSION: In the management of elbow prosthetic infection, 2-stage revision arthroplasty using PROSTALAC spacer insertion in the first stage and cortical strut allograft in the second stage for patients with severe bone defect revealed good clinical results and relatively low infection recurrence rates. However, the complication rate is substantial.

The Cost-Effectiveness of Silver-Impregnated Occlusive Dressings for Infection Prevention After Total Joint Arthroplasty.

BACKGROUND: Prosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty that exacts a substantial economic burden on the health-care system. This study used break-even analysis to investigate whether the use of silver-impregnated occlusive dressings is a cost-effective measure for preventing PJI after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: Baseline infection rates after TKA and THA, the cost of revision arthroplasty for PJI, and the cost of a silver-impregnated occlusive dressing were determined based on institutional data and the existing literature. A break-even analysis was then conducted to calculate the minimal absolute risk reduction needed for cost-effectiveness. RESULTS: The use of silver-impregnated occlusive dressings would be economically viable at an infection rate of 1.10%, treatment costs of $25,692 for TKA PJI, and $31,753 for THA PJI and our institutional dressing price of $38.05 if it reduces infection rates after TKA by 0.15% (the number needed to treat [NNT] = 676) and THA by 0.12% (NNT = 835). The absolute risk reduction needed to maintain cost-effectiveness did not change with varying initial infection rates and remained less than 0.40% (NNT = 263) for infection treatment costs as low as $10,000 and less than 0.80% (NNT = 129) for dressing prices as high as $200. CONCLUSION: The use of silver-impregnated occlusive dressings is a cost-effective measure for infection prophylaxis after TKA and THA.

Silver-coated megaprosthesis in prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about efficacy and toxicity in primary and revision surgery.

AIM: Prosthetic joint infection (PJI) is a common complication following orthopedic megaprosthetic implantations (EPR), estimated up to 50%. Silver coatings were introduced in order to reduce the incidence of PJI, by using the antibacterial activity of silver. Three different silver coatings are available: MUTARS® (Implantcast), Agluna® (Accentus Medical), PorAg® (Waldemar Link). The aim of this review is to provide an overview on efficacy and safety of silver-coated EPR both in primary and revision surgery, comparing infection rate according to the type of implant. METHODS: Through an electronic systematic search, we reviewed the articles concerning silver-coated EPRs. Infection rate, silver-related complications, local and blood concentrations of the silver were evaluated. Meta-analyses were performed to compare results from each study included. RESULTS: Nineteen studies were included. The overall infection rate in patients with silver-coated implants was 17.6% (133/755). Overall infection rate in primary silver-coated EPR was been 9.2% (44/445), compared to 11.2% (57/507) of non-silver-coated implants. The overall infection rate after revisions was 13.7% (25/183) in patients with silver-coated EPR and 29.2% (47/161) when uncoated EPR were used, revealing a strength statistically significative utility of silver coatings in preventing infections in this group (p: 0.019). Generally, the use of MUTARS® EPR had produced an almost constant decrease in the incidence of primary PJI but there are few data on the effectiveness in revisions. The results from the use of Agluna® in both primary and revisions implants are inconstant. Conversely, PorAg® had proven to be effective both in PJI prevention but, especially, when used in PJI revision settings. Local argyria was reported in 8 out of 357 patients (2.2%), while no systemic complications were described. Local and blood concentrations of silver were always reported very far to the threshold of toxicity, with the lowest concentration found using PorAg®. CONCLUSIONS: Silver-coated EPRs are safe and effective in reduction in PJI and re-infection rate, in particular when used in higher risk patients and after two-stage revisions to fight PJI.

Customized intraoperatively molded articulating cement spacers for two-stage revisions TKA with major bone defects.

BACKGROUND: The use of articulating spacers, molded or prefabricated, becomes difficult in case of severe bone losses. Our idea was to customize the Molded Articulating Cement Spacers with cement stem extensions and if necessary metaphyseal cement augmentations in order to use them also in case of major bone defects. METHODS: Fifty-four knees in fifty-three patients undergoing 2-stage exchange arthroplasty were divided in 4 groups, treated with 4 different types of spacers (Static, articulating molded, customized molded and metal on Poly) and evaluated in terms of Range of Motion (ROM), Knee Society Score (KSS), patients' related outcome measures (PROMs), rate of complication and ease of the surgical exposure at the time of reimplantation. RESULTS: At final follow-up, no statistical differences in terms of ROM and KSS were found between the articulating groups. Static Spacers showed statistically significant lower results both in terms of ROM and KSS comparing to the other 3 groups (P < 0.05). Considering PROMs, statistically better outcomes for all articulating spacers were found both when spacer was in place and at final follow-up comparing to the static spacers group (P < 0.05). No statistically significant difference was found between the 3 articulating spacers groups. Radiographic analysis did not show signs of loosening, migration or major bone loss. CONCLUSIONS: Customized Intraoperatively Molded Articulating Cement Spacers are a safe solution for two-stage revisions TKA with major bone defects and may provide a better quality of life for patients when in place comparing to static ones.

[Multi-component multi-stage treatment of a patient with infection of thoracic aorta prosthesis, deep sternal wound infection and soft tissue deficit of the chest]. / Mnogokomponentnoe, mnogoetapnoe lechenie patsientki s infektsiei proteza vsei grudnoi aorty, osteomielitom grudiny i defitsitom myagkikh tkanei grudnoi kletki.

We report a comorbid patient after redo Frozen Elephant Trunk procedure followed by recurrent infection of thoracic aortic prosthesis, deep sternal wound infection and extensive soft tissue defect. Closure with skin-muscle thoracodorsal flap and graft-sparing technique with omentoplasty is an alternative to total graft replacement for thoracic aortic graft infection in comorbid patients with concomitant extensive defect of the chest wall or recurrent infection in early postoperative period.

Recurrent Aortic Infections Due to Unrecognized Aorto-Enteric Fistula.

We report a case of an infrarenal abdominal aortic aneurysm (AAA) with unrecognized primary aortoduodenal fistula (ADF), treated by endovascular aortic repair (EVAR). Endograft infection was diagnosed 12 months thereafter. The associated ADF was uncovered during open surgery, which included endograft extraction, in situ aortic reconstruction with a cryopreserved homograft (CHG) and duodenal repair. The patient was urgently reoperated in the early postoperative course, due to CHG rupture and subsequent hemorrhagic shock. After establishing control of hemorrhage, CHG was explanted, followed by aortic ligation and extraanatomical reconstruction with axillofemoral bypass. The importance of timely diagnosis of primary ADF prior to AAA repair, as well as treatment options and optimal materials for simultaneous aortic and bowel reconstruction in the setting of primary or secondary ADF, are discussed.

Successful treatment of thoracic aortic graft infection by omental flap following vacuum-assisted closure therapy.

BACKGROUND: Postoperative thoracic aortic graft infection (TAGI) is a serious and potentially fatal complication. The classical approach is to replace the infected graft. However, this approach has a high mortality rate. Alternatively, treatment of TAGI without graft replacement can be performed METHOD: Herein, we present a 72-year-old case with mediastinitis and graft infection after type A aortic dissection operation and successful treatment using omental flap coverage following vacuum-assisted wound closure therapy without graft replacement. CONCLUSION: The patient had an uneventful postoperative course and remains infection-free to date.

Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model.

BACKGROUND: Recent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA). METHODS: A cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion. RESULTS: Selective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%. CONCLUSION: This predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.

Spacer Design Options and Consideration for Periprosthetic Joint Infection.

An articulating or nonarticulating antibiotic hip spacer can be placed following the first stage implant removal of a periprosthetic hip joint infection. Antibiotic spacers help fill in the dead space created at the time of resection and provide a high local concentration of antibiotics. Theoretical advantages of a static spacer include a higher elution of antibiotics because of the increased surface area, the ability to protect deficient bone in the proximal femur/acetabulum, and the ability to immobilize the periarticular soft tissues. Advantages of an articulating spacer include improved ambulation and easier motion for the patient, maintenance of soft tissue tension, and an easier surgical reconstruction at the time of the second stage. Additionally, an articulating antibiotic spacer may minimize the risk of dislocation following the second stage reconstruction. The choice of articulating or nonarticulating is currently one of surgeon preference yet it is advised that surgeons consider an articulating spacer for all patients except those with severe femoral/acetabular bone loss or deficient abductors.

Point/Counterpoint: Static vs Articulating Spacers-Static Spacers for Resection Arthroplasty of the Knee.

Antibiotic spacers play a significant role in the treatment of periprosthetic joint infections. They help maintain soft-tissue tension and provide delivery of high dose of antibiotics to the local tissue. The use of static or dynamic spacers is based on multiple factors including the extent of soft-tissue, ligamentous and bone compromise, overall patient function, comorbid conditions, and virulence of the organism. There is no difference in reinfection incidence between static vs dynamic spacers following two-stage reimplantation. Static spacers can be customized to treat all cases of periprosthetic total knee infections and offer intraoperative flexibility to vary the cement quantity and amount of antibiotics in the spacer to provide high-dose local delivery of antibiotics to address the dead space, bone loss, and soft-tissue compromise. Static spacers are especially advantageous in cases of extensor mechanism and ligamentous compromise where articulating spacers may not be able to provide adequate stability.

Point/Counterpoint: Nonarticulating vs Articulating Spacers for Resection Arthroplasty of the Knee or Hip.

Two-stage exchange arthroplasty remains the gold standard for chronic total knee arthroplasty (TKA) and total hip arthroplasty infections in North America. Cement spacers impregnated with high-dose antibiotics have been successfully used in the interim period of the 2-stage exchange process. A number of spacers have been described; however, this article will focus on articulating spacers. In the presence of an intact extensor mechanism (for TKA), reasonable soft tissue envelope, and adequate bone, articulating antibiotic spacers provide several advantages. These include an infection eradication rate of approximately 90%, higher range of motion after reimplantation, and lower complication rates when compared with nonarticulating spacers. In the appropriate patient, articulating antibiotic spacers are an effective and a safe treatment for infected TKAs and total hip arthroplasties.

Two-Stage Treatment for Total Knee Arthroplasty Infection Utilizing an Articulating Prefabricated Antibiotic Spacer.

Periprosthetic joint infection represents a serious complication following total knee arthroplasty. In the setting of chronic or age-indeterminate total knee arthroplasty infection, a 2-staged approach has been traditionally the preferred method of treatment over single-stage debridement and reimplantation debridement or debridement, antibiotics and implant retention. Two-stage is the preferred treatment method in North America and has demonstrated better overall success than the single stage techniques. Additionally, the 2-stage method is the preferred treatment for difficult to treat pathogens as well as in patients who have already undergone a previous revision procedure. An articulating prefabricated antibiotic spacer has entered the armamentarium of 2-stage revision knee surgery, and has demonstrated comparable results to custom and static spacers in terms of the primary goal of infection control. Importantly, the potential for enhanced mobility and function hold promise by safely providing a more "livable" knee during the convalescent period prior to definitive reimplantation.

Comparison of Traditional Molded, First-Generation Premolded, and Second-Generation Premolded Antibiotic-Loaded Polymethylmethacrylate Articulating Spacers for Treatment of Chronic Prosthetic Joint Infection of the Knee.

BACKGROUND: The purpose of this study was to compare patients who had chronic prosthetic joint infection treated using three methods of articulating polymethylmethacrylate spacers in two-stage reimplantation. METHODS: We identified 77 patients who had chronic prosthetic joint infection with a minimum of one-year follow-up. Reinfection rates were determined using modified International Consensus group criteria. RESULTS: The overall reinfection rate was 18% (14 of 77 patients). Despite a higher medical comorbidity in the second-generation spacer cohort, there were no statistical differences in reinfection rates between articulating spacer types. CONCLUSION: This study suggests that there were no differences in efficacy between the traditional molded, first-generation premolded, and second-generation premolded articulating spacers, but more studies with high level of evidence are needed.

Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients.

Background and purpose - The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI. Patients and methods - A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received. Results - For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28-35), 39 (25-59), and 23 (15-34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24-31), 40 (24-62), and 24 (16-36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders. Interpretation - In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.

Clinical Effectiveness of Treatment Strategies for Prosthetic Joint Infection Following Total Ankle Replacement: A Systematic Review and Meta-analysis.

Prosthetic joint infection (PJI) after total ankle replacement (TAR) is a challenging complication, which often requires debridement and implant retention (DAIR) with or without polyethylene exchange, revision surgery, implantation of a cement spacer, conversion to arthrodesis, or even amputation. The optimum treatment for ankle PJI is not well established. We conducted a systematic review and meta-analysis to compare the clinical effectiveness of various treatment strategies for infected ankle prostheses. We searched MEDLINE, Embase, Web of Science, and the Cochrane Library up to December 2018 for studies evaluating the impact of treatment in patient populations with infected ankle prostheses following TAR. Binary data were pooled after arcsine transformation. Six citations comprising 17 observational design comparisons were included. The reinfection rates (95% confidence intervals) for DAIR with or without polyethylene exchange, 1-stage revision, 2-stage revision, cement spacer, and arthrodesis were 39.8% (24.4 to 56.1), 0.0% (0.0 to 78.7), 0.0% (0.0 to 8.5), 0.2% (0.0 to 17.9), and 13.6% (0.0 to 45.8), respectively. Rates of amputation for DAIR with or without polyethylene exchange and cement spacer were 5.6% (0.0 to 16.9) and 22.2% (6.3 to 54.7), respectively. Measures of function, pain, and satisfaction could not be compared because of limited data. One- and 2-stage revision strategies seem to be associated with the lowest reinfection rates, but these findings are based on limited data. Arthrodesis and DAIR with or without polyethylene exchange appear to be commonly used in treating infected ankle prosthesis, but are associated with poor infection control. Clear gaps exist in the literature, and further research is warranted to evaluate treatment strategies for infected ankle prosthesis.

Do Antibiotic Intramedullary Dowels Assist in Eradicating Infection in Two-Stage Resection for Septic Total Knee Arthroplasty?

BACKGROUND: Evidence suggests approximately 40% of intramedullary (IM) canals are culture positive at resection for infected knee arthroplasty. While commonly utilized, no clinical data on the efficacy of antibiotic-eluding IM dowels exist. We quantified treatment success with and without the use of antibiotic-eluding IM dowels in two-stage treatment of periprosthetic knee infection using static and articulating antibiotic cement spacers. METHODS: 109 consecutive patients who underwent two-stage treatment for periprosthetic knee infection were reviewed. Treatment failure, defined as repeat resection before reimplantation or recurrent infection within 6 months of reimplantation, was evaluated based on spacer type and use of IM dowels, accounting for infection type and systemic host and local extremity grade. RESULTS: After exclusions for confounds, articulating spacers without IM dowels were used in 49 (57.7%) cases, articulating spacers with IM dowels in 14 cases (16.5%), and static spacers with IM dowels in 22 (25.9%) cases. Treatment success regardless of infection classification was 85.7% for articulating spacers with IM dowels, 89.8% for articulating spacers without IM dowels, and 68.2% for static spacers with IM dowels (P = .074). In chronically infected poor hosts with compromised extremities, treatment success remained highest in patients with articulating spacers with (90.9%) or without (92.9%) IM dowels compared with static spacers with IM dowels (68.4%) (P = .061). CONCLUSION: Findings suggest that the use of IM dowels did not enhance infection eradication above and beyond that observed for articulating spacers alone, including in the worst cases involving chronically infected poor hosts with compromised extremities.