Efficacy and safety of two-stage revision for patients with culture-negative versus culture-positive periprosthetic joint infection: a single-center retrospective study.

BACKGROUND: The safety and efficacy of two-stage revision for culture-negative PJI remain controversial. This study analyzed outcomes after two-stage revision in patients with culture-negative and culture-positive periprosthetic joint infection (PJI) during follow-up lasting at least two years. METHODS: Data were retrospectively analysed patients who underwent hip or knee revision arthroplasty from January 2008 to October 2020 at our medical center. The primary outcome was the re-revision rate, while secondary outcomes were the rates of reinfection, readmission, and mortality. Patients with culture-negative or culture-positive PJI were compared in terms of these outcomes, as well as survival time without reinfection or revision surgery, based on Kaplan‒Meier analysis. RESULTS: The final analysis included 87 patients who were followed up for a mean of 72.3 months (range, 24-123 months). The mean age was 58.1 years in the culture-negative group (n = 24) and 59.1 years in the culture-positive group (n = 63). The two groups (culture-negative versus culture-positive) did not differ significantly in rates of re-revision (0.0% vs. 3.2%, p > 0.05), reinfection (4.2% vs. 3.2%, p > 0.05), readmission (8.4% vs. 8.0%, p > 0.05), or mortality (8.3% vs. 7.9%, p > 0.05). They were also similar in survival rates without infection-related complications or revision surgery at 100 months (91.5% in the culture-negative group vs. 87.9% in the culture-positive group; Mantel‒Cox log-rank χ2 = 0.251, p = 0.616). CONCLUSION: The two-stage revision proves to be a well-tolerated and effective procedure in both culture-negative and culture-positive PJI during mid to long-term follow-up.

Static spacers play a crucial role in the treatment of complex periprosthetic joint infections of the knee.

PURPOSE: To determine the superior spacer design, a growing number of studies are comparing treatment results between patients having been treated with articulating and static knee spacers in the setting of two-stage revision for periprosthetic joint infection (PJI). In contrast, the primary objective of this study was to compare preoperative characteristics between patients from both spacer groups and examine whether significant differences were present prior to spacer implantation. METHODS: This retrospective, single-centre, cohort study examined the preoperative situation of 80 consecutive knee PJIs between 2017 and 2020. All patients underwent two-stage revision, with 35 (44%) receiving an articulating and 45 (56%) a static spacer. RESULTS: No significant differences were observed in terms of patient gender (p = 0.083), age (p = 0.666), comorbidity (p = 0.1) and preoperative clinical function (p = 0.246). Static spacers were significantly more often used in the presence of a periarticular fistula (p = 0.033), infection of a revision implant (p < 0.001), higher degree of bone loss (p < 0.001) and infection caused by a difficult-to-treat pathogen (p = 0.038). Complication and revision rates were similar for both spacer types during the interim period, while patients with articulating spacers demonstrated a superior clinical function (p < 0.001) during the interim period and after reimplantation. CONCLUSION: Static spacers are being utilised in significantly more complex and unfavourable preoperative scenarios. Therefore, a preoperative selection bias may be at least partially accountable for any disparities observed in postoperative outcomes. To achieve the best possible results, surgeons should know and respect the distinct indications of static and articulating spacers and consequently understand and use them as complementary surgical options. LEVEL OF EVIDENCE: Level III.

Does retained cement or hardware during 2-stage revision shoulder arthroplasty for infection increase the risk of recurrent infection?

BACKGROUND: When treating chronic prosthetic joint infection after shoulder arthroplasty, removal of the implants and cement is typically pursued because they represent a potential nidus for infection. However, complete removal can increase morbidity and compromise bone stock that is important for achieving stable revision implants. The purpose of this study is to compare the rates of repeat infection after 2-stage revision for prosthetic joint infection in patients who have retained cement or hardware compared to those who had complete removal. MATERIALS AND METHODS: We retrospectively analyzed all two-stage revision total shoulder arthroplasties performed for infection at 2 institutions between 2011 and 2020 with minimum 2-year follow-up from completion of the two-stage revision. Patients were included if they met the International Consensus Meeting criteria for probable or definite infection. Postoperative radiographs after the first-stage of the revision consisting of prosthesis and cement removal and placement of an antibiotic spacer were reviewed to evaluate for retained cement or hardware. Repeat infection was defined as either ≥2 positive cultures at the time of second-stage revision with the same organism cultured during the first-stage revision or repeat surgery for infection after the two-stage revision in patients that again met the International Consensus Meeting criteria for probable or definite infection. The rate of repeat infection among patients with retained cement or hardware was compared to the rate of infection among patients without retained cement or hardware. RESULTS: Thirty-seven patients met inclusion criteria and were included in the analysis. Six (16%) patients had retained cement and 1 patient (3%) had 2 retained broken glenoid baseplate screws after first-stage revision. Of the 10 cases of recurrent infection, 1 case (10%) involved retained cement/hardware. Age at revision (60.9 ± 10.6 vs. 65.0 ± 9.6, P = .264), body mass index (33.4 ± 7.2 vs. 29.7 ± 7.3, P = .184), Charlson Comorbidity Index (2 (0-8) vs. 3 (0-6), P = .289), male sex (7 vs. 16, P = .420), and presence of diabetes (1 vs. 3, P = .709) were not associated with repeat infection. Retained cement or hardware was also not associated with a repeat risk of infection (1 vs. 6, odds ratio = 0.389, P = .374). DISCUSSION: We did not find an increased risk of repeat infection in patients with retained cement or hardware compared to those without. Therefore, we believe that surgeons should consider leaving cement or hardware that is difficult to remove and may lead to increased morbidity and future complications.

Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis.

BACKGROUND: There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty. METHODS: Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model. RESULTS: After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I2 = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I2 = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03). CONCLUSIONS: This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.

Validity of a preoperative scoring system for surgical management of periprosthetic hip infection: one-stage vs. two-stage revision.

INTRODUCTION: There are no widely accepted algorithms for determining optimal treatment for periprosthetic joint infection (PJI). Our study aimed to confirm the validity of a previously published scoring system in a larger number of patients to support a rational surgical treatment strategy for periprosthetic hip infection. MATERIALS AND METHODS: Between February 2001 and December 2020, we performed 155 consecutive revision total hip arthroplasties (THAs) for PJI, with mean follow-up of 6 years. One-stage revision THA was performed in 56 hips and two-stage revision THA in 99 hips. Prosthesis survival from recurrent infection was determined by Kaplan-Meier analysis, using implant removal as the endpoint. The pre-operative scoring system (full score of 12 points), including 6 essential elements, was retrospectively evaluated. RESULTS: The 10-year survival rates were 98% for one-stage (95% confidence interval [CI], 94-100) and 87% (95% CI, 79-96) for two-stage revision THA. Multivariate Cox regression analysis provided a total preoperative score as an independent risk factor for implant removal (hazard ratio, 0.17; 95% CI, 0.06-0.49; p < 0.001). The sensitivity and specificity at the cut-off of 4 points on the scoring system were 80% and 91%, respectively. The average score for one-stage revision THA in successful and failed cases were 8.9 and 6.0, and for two-stage revision THA were 6.5 and 3.9, respectively. We found significant differences between successful cases in one- and two-stage revision THA (p < 0.05). CONCLUSIONS: The preoperative scoring system was useful for managing PJI. One-stage revision THA is recommended in patients scoring ≥ 9 points, and meticulously performed two-stage revision THA is encouraged for patients scoring ≥ 4 points.

A case report on Mycobacterium houstonense infection after total hip arthroplasty.

BACKGROUND: Mycobacterium houstonense is a category of rapidly growing mycobacteria that is gram-positive, acid-fast, polycrystalline, and non-spore-forming. There have been few reports of human infection caused by Mycobacterium houstonense worldwide. CASE PRESENTATION: We present a case of chronic periprosthetic joint infection caused by Mycobacterium houstonense in an elderly female patient. The patient developed signs of infection after undergoing total hip arthroplasty. Despite receiving antibiotic treatment and revision surgery, the signs of infection recurred repeatedly. Multiple bacterial cultures during the treatment period were negative. Later, we identified the pathogenic bacteria Mycobacterium houstonense through mNGS testing, isolated the bacteria from the ultrasonically centrifuged fluid of the prosthesis and obtained drug sensitivity results. Finally, we performed a revision surgery and treated the patient with moxifloxacin and clindamycin. After treatment, the patient did not show signs of infection recurrence during 24 months of follow-up. CONCLUSION: Through a relevant literature search, we believe that Mycobacterium houstonense may show higher sensitivity to amikacin and quinolone antibiotics. Additionally, clarifying occult infection sources through methods such as gene testing will improve the diagnosis and treatment of periprosthetic joint infection.

The durability of revisional sleeve gastrectomy and Roux-en-Y gastric bypass after previous adjustable gastric band.

BACKGROUND: Patients with adjustable gastric banding (AGB) often require revision to one-stage or two-stage sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). OBJECTIVE: To compare the long-term durability of revisional SG and RYGB, in terms of subsequent revision or conversion (RC). METHODS: The New York Statewide Planning and Research Cooperative Systems dataset was queried from 2006 to 2013 for patients who underwent primary SG and RYGB, one-stage, and two-stage conversion from AGB to SG and RYGB. Patients who required RC were identified. A multivariable Cox proportional hazard model was used to compare the RC risk among these groups. RESULTS: 13,749 had primary SG, 621 one-stage, and 321 two-stage AGB to SG. 31,814 had primary RYGB, 555 one-stage, and 248 two-stage AGB to RYGB. The estimated 5-year cumulative RC incidence rate was significantly lower after primary surgery than after prior AGB (one-stage AGB to SG 14.4%, two-stage AGB to SG 11.6%, primary SG 5.2%, one-stage AGB to RYBG 3.4%, two-stage AGB to RYGB 2.9%, and primary RYGB 1.1%, p-value < 0.0001). RYGB and SG did not differ significantly in terms of the elevation effect of one- and two-stage AGB conversion over primary surgeries (RYGB vs SG: one stage vs primary ratio of HR = 0.97, 95% CI = [0.58, 1.63], p-value = 0.9153; two stage vs primary ratio of HR = 1. 02, 95% CI = [0.50, 2.07], p-value = 0.9596). CONCLUSION: RC after AGB to SG or RYGB is more frequent compared to primary surgeries with procedures following AGB to SG being more common than AGB to RYGB. However, that difference was proportionally similar to the RC rate ratio differences noted for primary SG and RYGB.

Modern Description of Antibiotic Spacer Options for PJI in Revision Total Knee Arthroplasty: Clinical Outcomes and Infection Eradication Rates.

BACKGROUND: As the burden of periprosthetic joint infections (PJIs) increases, there is growing interest in understanding the efficacy and morbidity reduction of 2-stage revision and various antibiotic spacer options. This study aimed to expand the description and evaluation of spacers from solely their articulation status to include their ability to support full (functional) or partial weight-bearing (nonfunctional). METHODS: Between 2002 and 2021, 391 patients who had Musculoskeletal Infection Society criteria for PJI with 1-stage or 2-stage revision were included. Demographics, functional outcomes, and subsequent revision data were collected. The study population had a mean follow-up of 2.9 years (range, 0.05-13.0) with an average age of 67 years (range, 34.7-93.4). Spacer failure was defined by surgical intervention following definitive surgery, and infection eradication was defined by the Delphi criteria. Spacers were classified as nonfunctional static, nonfunctional dynamic, functional static, or functional dynamic. Two tailed t-tests were performed. RESULTS: There were no significant differences in infection eradication or mechanical outcomes across spacer types; notably, 97.3% of functional dynamic spacers achieved infection eradication. Functional spacers had a longer time to the second stage procedure and a greater number of patients who had not been reimplanted. There was no difference in reoperation rates in nonfunctional versus functional spacers. CONCLUSION: Within this cohort, infection eradication and spacer exchange rates were noninferior among spacers. Functional spacers may allow for earlier return to daily living given the weight-bearing capability when compared to nonfunctional, without sacrificing clinical outcome.

Clinical and Functional Outcomes of Extended Trochanteric Osteotomy in 2-Stage Revision Total Hip Arthroplasty for Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Extended trochanteric osteotomy (ETO) has long been used in 2-stage revision surgeries of the hip, for both aseptic and septic indications. The purpose of this systematic review is to summarize the cumulative occurrence rates of the clinical and functional outcomes associated with the use of ETO in 2-stage revision total hip arthroplasty for periprosthetic joint infection. METHODS: PubMed/MEDLINE and the Cochrane Database of Systematic Reviews databases were searched for articles published from January 1980 to January 2022 using the following keywords: "extended" AND "trochanteric" AND "osteotomy" AND "infection." Cumulative occurrence rates of outcomes and complications were calculated. A fixed-effects model and a 95% CI were applied. A P value of .05 was considered the significance threshold. RESULTS: Nine studies were in full compliance with the inclusion criteria, with a total population size across all studies of 378. Union and infection eradication rates among studies were 95.1% (95% CI, 92.7-97.1, P = .018) and 94.0% (95% CI, 91.1-96.4, P = .089), respectively. Postoperation complications occurred in 15.34% of patients (95% CI, 10.34-21.22, P = .066). Occurrence rates for stem subsidence, dislocation, and femoral fractures were 6.2% (95% CI, 3.3-9.9, P = .187), 7.6% (95% CI, 4.8-10.9, P = .075), and 9.1% (95% CI, 5.8-13, P = .106), respectively. CONCLUSION: With high rates of union and infection eradication, and low rates of postoperation complications, this study concludes the use of ETO in performing 2-stage revision total hip arthroplasty for the septic hip to be effective and safe.

Can serum C-reactive protein determine the timing of reimplantation in two-stage revised arthroplasty for periprosthetic hip infection?

BACKGROUND: There are no definitive guides to determine the timing of reimplantation in two-stage revision total hip arthroplasties (THA) for periprosthetic joint infection (PJI). This study was to design to support a rational strategy of surgical treatment using serum C-reactive protein (CRP). METHODS: We analyzed a total of 75 hips for PJI in the process of performing two-stage and multiple-stage revision THAs. CRP level was retrospectively evaluated every week and transformed to log2 (CRP) using a logistic regression model. Prosthesis survival from recurrent infection was determined by Kaplan-Meier analysis, using implant removal as the endpoint. Receiver operating characteristic curves were calculated using each log2 (CRP) to assess predictions of recurrent infection. RESULTS: The 10-year survival rates were 85% (95% confidence interval, 76-95) and 100% for two-stage and multiple-stage revision THAs, respectively. Preoperatively, at 1, 2, 3, and 5 weeks, log2 (CRP) was not associated with recurrent infection. In failed two-stage revision THAs, log2 (CRP) at 3 weeks divided by that at 2 weeks showed a significant difference. Failure was associated with a ratio of >4.0 for the CRP level between 3 and 2 weeks. CONCLUSION: In two-stage revision THA for PJI, patients with CRP elevation from 2 weeks to 3 weeks, especially 4-fold elevation, suggests the need for further debridement and postponement of second-staged reimplantation.

Enhanced antibiotic release from bone cement spacers utilizing dual antibiotic loading with elevated vancomycin concentrations in two-stage revision for periprosthetic joint infection.

PURPOSE: Antibiotic loaded bone cement spacers provide high local antibiotic concentrations, preserve bone stock, and reduce soft tissue contractions. The objective of this in-vitro study was to compare antibiotic release from spacers, aiming to discover the most optimal preparation and identify modifiable factors that can further enhance antibiotic release. METHODS: Six distinct spacer preparation were created using three different bone cements and manual incorporation of antibiotics. During a six-week period, the release of antibiotics from each spacer was measured individually at ten predetermined time points using a chemiluminescent immunoassay. RESULTS: Manually adding 4 g of vancomycin to every 40 g of "Palacos R + G" yielded the most favorable release profile. Throughout all preparations, antibiotic release consistently and significantly decreased over the six-week period. When incorporating a higher concentration of vancomycin, a significantly higher cumulative release of vancomycin was observed, with varying effects on the release of gentamicin. The choice of bone cement had a significant impact on antibiotic release. CONCLUSION: To enhance antibiotic release from spacers, surgeons should manually incorporate high antibiotic concentrations into the most appropriate bone cement and keep the interim period as short as possible. Specifically, we suggest manual incorporation of 4 g of vancomycin to every 40 g of gentamicin premixed "Palacos R + G" to create bone cement spacers.

The fate of fungal periprosthetic joint infection after total knee arthroplasty.

PURPOSE: To demonstrate the clinical outcomes of patients with fungal periprosthetic joint infections (PJIs) after two-stage exchange arthroplasty combined with antifungal therapy. METHODS: We retrospectively reviewed the outcomes of 41 patients with fungal PJIs after primary total knee arthroplasty (TKA) in a single centre from January 1999 to October 2017. During the first stage of resection arthroplasty, antifungal-impregnated cement spacers (AICSs) were implanted in all patients. After systemic antifungal treatment during the interval between the two surgeries, delayed reimplantation as part of a two-stage exchange protocol was performed when patients were clinically stable. We defined treatment success as a well-functioning arthroplasty without any signs of PJI after a minimum follow-up of two years without antimicrobial suppression. Successful treatment was confirmed by repeat negative cultures as well as a return of inflammatory markers to normal levels. RESULTS: The treatment success rate was 63.4% at the final follow-up. Thirty-six of 41 patients (87.8%) met the criteria for second-stage revision after confirmation of complete infection control. The mean prosthesis-free interval was 6.6 months (range, 2.0-30.0 months). During follow-up after two-stage exchange arthroplasty, ten patients (27.7% of 36 patients) unfortunately experienced recurrence or relapse of infection after an average of 31.3 months (range, 2.7-135.6 months). The rate of survivorship free from reinfection was 94.4% at six months, 84.8% at one year, and 73.6% at two years. Cox proportional hazard regression analysis demonstrated that the prosthesis-free interval (HR = 1.016, p = 0.037) and mean length of antifungal treatment (HR = 0.226, p = 0.046) were potential risk factors for failure. CONCLUSION: Fungal PJIs led to devastating clinical outcomes despite even two-stage revision arthroplasty with the use of AICSs and antifungal medications.

Two-stage revision for periprosthetic joint infection in cemented total hip arthroplasty: an increased risk for failure?

BACKGROUND: The impact of the prior fixation mode on the treatment outcome of chronic periprosthetic joint infection (PJI) of the hip is unclear. Removal of cemented total hip arthroplasty (THA) is particularly challenging and residual cement might be associated with reinfection. This study seeks to compare the results of two-stage revision for PJI in cemented and cementless THA. METHODS: We reviewed 143 consecutive patients undergoing two-stage revision THA for PJI between 2013 and 2018. Thirty-six patients with a fully cemented (n = 6), hybrid femur (n = 26) or hybrid acetabulum (n = 4) THA (cemented group) were matched 1:2 with a cohort of 72 patients who underwent removal of a cementless THA (cementless group). Groups were matched by sex, age, number of prior surgeries and history of infection treatment. Outcomes included microbiological results, interim re-debridement, reinfection, all-cause revision, and modified Harris hip scores (mHHS). Minimum follow-up was 2 years. RESULTS: Compared with PJI in cementless THA, patients undergoing removal of cemented THA had increasingly severe femoral bone loss (p = 0.004). Patients in the cemented group had an increased risk for positive cultures during second-stage reimplantation (22% compared to 8%, p = 0.043), higher rates of reinfection (22% compared to 7%, p = 0.021) and all-cause revision (31% compared to 14%, p = 0.039) compared to patients undergoing two-stage revision of cementless THA. Periprosthetic femoral fractures were more frequent in the group of patients with prior cementation (p = .004). Mean mHHS had been 37.5 in the cemented group and 39.1 in the cementless group, and these scores improved significantly in both groups (p < 0.01). CONCLUSION: This study shows that chronic infection in cemented THA might be associated with increased bone loss, higher rates of reinfection and all-cause revision following two-stage revision. This should be useful to clinicians counselling patients with hip PJI and can guide treatment and estimated outcomes.

Clinical evaluation of a new technique for custom-made spacers in septic two-stage revision of total hip arthroplasties.

INTRODUCTION: In septic two-stage revision surgery, success depends on numerous factors. Key steps are the procedure of ex- and reimplantation and the choice of spacer in the interim phase. The latter is still a matter of debate. Recently, we showed the microbial non-inferiority of a spacer technique using prosthetic cemented implants with an individualized antibiotic mixture in the cement applying a mechanically inferior cementation method. The aim of the present study was to evaluate the clinical results of these spacers in view of either an endofemoral or a transfemoral procedure. MATERIALS AND METHODS: Our collective consisted of 86 patients (45 endofemoral and 41 transfemoral procedures). The collective was analyzed with respect to complications, reinfection rate and clinical status at the end of the interim phase. Results of an endofemoral and transfemoral approach were compared. RESULTS: With a median Staffelstein-Score of 60 (range 31-81) at the end of the interim phase, the first clinical results are promising. The reinfection-free rate after a median follow-up of 50 months was 90%. Spacer-related complications occurred in 8% of the total collective. Comparing the endo- and transfemoral procedure, there were no statistical differences in complications or regarding the clinical and infectiological outcome. CONCLUSIONS: In this study, we were able to show good clinical results for the presented spacer technique. With no relevant difference in outcome, the decision for an endofemoral or transfemoral technique can be based on technical deliberations. Further prospective comparative studies are necessary to show the clinical benefit of this procedure.

Indications and techniques for non-articulating spacers in massive bone loss following prosthetic knee joint infection: a scoping review.

INTRODUCTION: Prosthetic joint infection (PJI) is a destructive complication of knee replacement surgery (KR). In two-stage revision a spacer is required to maintain limb length and alignment and provide a stable limb on which to mobilise. Spacers may be articulating or static with the gold standard spacer yet to be defined. The aims of this scoping review were to summarise the types of static spacer used to treat PJI after KR, their indications for use and early complication rates. METHODS: We conducted a scoping review based on the Joanna Briggs Institute's "JBI Manual for Evidence Synthesis" Scoping review reported following Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. MEDLINE, EMBASE and CINAHL were searched from 2005 to 2022 for studies on the use of static spacers for PJI after KR. RESULTS: 41 studies (1230 patients/knees) were identified describing 42 static spacer constructs. Twenty-three (23/42 [54.2%]) incorporated cement augmented with metalwork, while nineteen (19/42, [45.9%]) were made of cement alone. Spacers were most frequently anchored in the diaphysis (22/42, [53.3%]), particularly in the setting of extensive bone loss (mean AORI Type = F3/T3; 11/15 studies 78.3% diaphyseal anchoring). 7.1% (79 of 1117 knees) of static spacers had a complication requiring further surgery prior to planned second stage with the most common complication being infection (86.1%). CONCLUSIONS: This study has summarised the large variety in static spacer constructs used for staged revision KR for PJI. Static spacers were associated with a high risk of complications and further work in this area is required to improve the quality of care in this vulnerable group.

Two-stage revision for treatment of tuberculous prosthetic hip infection: an outcome analysis.

OBJECTIVES: Prosthetic joint infections (PJI) and especially tuberculosis (TB) PJI are rare diseases and hard to cure. The effectiveness of treatments for tuberculous PJI still remains a problem. The objective of this research was to indicate the success of two-stage revision replacement and also giving the associated criteria. METHODS: From 2015 to 2020, five patients with tuberculous PJI were treated with two-stage revision at Cho Ray hospital, Vietnam. We collected the dataset which included demographic data, the interval from the time of joint replacement to reported infection, records of tuberculous PJI, administration of anti-TB medications (duration, months), history of operation(s), duration of follow-up, and specific type(s) of antibiotics loaded in bone cement. The approval for this study was made by the institutional review board from Cho Ray Hospital, Vietnam. We conducted a literature review based on the keywords "PJI" and "TB" on PubMed. RESULTS: Five patients [median age 66 years (range 35-84)] had found tuberculous PJI. The median time from arthroplasty to diagnosis was 19 months (range 4-48). The diagnosis was confirmed by joint aspirates or synovial tissue. Positive PCR was also reported in all cases. The average duration of anti-tuberculosis polytherapy administration was 14.4 months. The operative techniques on five patients included debridement and using spacer loaded with 2 g streptomycin (and 2 g vancomycin if they got a coinfection) for 1 pack of bone cement, and revision arthroplasty. In most cases, the outcome of treatment using two-stage revision replacement was 80%. Overall, the auxiliary bacterial infections were recognized in three patients with tuberculous PJI and Staphylococcus aureus. Streptomycin and vancomycin were loaded in a cement spacer to increase the success rate, and tuberculous PJI was controlled for all patients. CONCLUSION: Tuberculous PJI can be controlled with two-stage revision replacement with an antibiotic-loaded cement spacer that is molded intraoperatively with custom mold and prolonged anti-tuberculosis treatment in all cases. LEVEL OF EVIDENCE: IV.

Candida periprosthetic infection of the knee: a systematic review of surgical treatments and clinical outcomes.

BACKGROUND: Candida periprosthetic joint infections (PJIs) are a rare cause of prosthesis revision with severe consequences and challenging treatment. This study aims to produce a systematic analysis of types of treatment and outcome of knee Candida PJIs and their correlation with specific pathogen species. METHODS: During April 2021, a literature search was performed according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guideline. Reviewers used the Oxford Level of Evidence (LoE) and Methodological index for non-randomized studies (MINORS) score. Modal value of surgical, pharmacological treatment and outcome along with the correlation between types of treatment and outcome was calculated through Chi-square or Fisher exact test. RESULTS: In total, 115 cases were collected through 51 articles, identifying 116 pathogens. Candida albicans was the most frequent pathogen. Analysis of LoE reveals 40 LoE 5 and 11 LoE 4. Thirteen patients underwent one-stage revision, 46 patients two-stage revision, 6 patients resection arthroplasty and arthrodesis, 4 patients long-term antifungal therapy, and 3 patients debridement with prosthesis retention. Global rate of success was 85.14%. Modal distribution revealed a preference for two-stage revision and Fluconazole in medical therapy. No difference in terms of fungal eradication was found among Candida species (p = 0.503) and for treatments except for two-stage revision and resection arthroplasty (p = 0.0125) or debridement with implant retention (p = 0.0498), and the rest of procedures and resection arthroplasty (0.0192). MINORS score was poor. CONCLUSIONS: Analysis of the literature did not highlight any difference between types of surgical treatment and pathogens in terms of relapse or infection eradication. However, two-stage replacement may be preferred, allowing healing of infection in most cases.

Extended trochanteric osteotomy is a safe procedure in two-stage hip revision: a systematic review of the literature.

BACKGROUND: Extended trochanteric osteotomy (ETO) has proved to be an effective technique in complicated stem removal in femoral aseptic loosening or periprosthetic fracture. Debate remains about its safety in periprosthetic joint infection (PJI). The primary aim of this study is to analyze the ETO reinfection and union rate in two-stage hip revision. MATERIAL AND METHODS: A systematic literature review was performed regarding all studies reporting ETO outcomes in the two-stage revision for hip PJI up to October 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A literature search was conducted in the following databases: MEDLINE/EMBASE, Scopus, Web of Science, and Cochrane. Quality assessment of the articles was performed using the Methodological Index for Non-Randomized Studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews. Patient demographic, clinical, and surgical data were collected. RESULTS: This systematic review included and analyzed nine clinical studies with a total of 382 ETO PJI hips in two-stage revision. The overall ETO reinfection rate was 8.9% (34 hips), consistent with the reinfection rate after two-stage revision in patients without ETO. The overall ETO union rate was 94.8% (347 hips), comparable to the ETO union rate in non-septic patients. Compared between a group of patients with ETO PJI and a group of patients with non-PJI ETO, there were no significant differences in postoperative complications, both septic and aseptic, and for postoperative HHS. CONCLUSION: ETO proved to be a safe and effective procedure in PJI revisions. It may be a viable option in challenging femoral stem removal during the two-stage hip revision in PJI. LEVEL OF EVIDENCE: IV.

Sequential repeated tibial tubercle osteotomy in a two-stage exchange strategy: a superior approach to treating a chronically infected knee arthroplasty?

PURPOSE: Surgical approach can impact the reliability of the debridement after a chronic total knee periprosthetic joint infection (PJI), a factor of utmost importance to eradicate the infection. The most adequate knee surgical approach in cases of PJI is a matter of debate. The purpose of this study was to determine the influence of performing a tibial tubercle osteotomy (TTO) in a two-stage exchange protocol for knee PJI treatment. METHODS: Retrospective cohort study examining patients managed with two-stage arthroplasty due to chronic knee PJI (2010-2019). Performance and timing of the TTO were collected. Primary end-point was infection control with a minimum FU of 12 months and according to internationally accepted criteria. Correlation between TTO timing and reinfection rate was reviewed. RESULTS: Fifty-two cases were finally included. Overall success (average follow-up: 46.2 months) was 90.4%. Treatment success was significantly higher among cases addressed using TTO during the second stage (97.1% vs. 76.5%, p value 0.03). Only 4.8% of the patients relapsed after performing a sequential repeated TTO, that is, during both first and second stages, compared to 23.1% cases in which TTO was not done (p value 0.28). No complications were observed among patients in the TTO group with a significant decrease in soft tissue necrosis (p: 0.052). CONCLUSION: Sequential repeated tibial tubercle osteotomy during a two-stage strategy is a reasonable option and offers high rates of infection control in complex cases of knee PJI with a low rate of complications.

Risk factors of reinfection after prosthesis removal and antibiotic bone cement spacer implantation for the treatment of periprosthetic joint infection.

BACKGROUND: Prosthesis removal and antibiotic bone cement spacer implantation is a very important link in two-stage revision of periprosthetic joint infection (PJI) after artificial joint replacement, which is key to the smooth progress of second-stage revision surgery. There are few reports on the risk factors of reinfection after prosthesis removal and antibiotic bone cement spacer implantation for PJI. This study aimed to investigate the risk factors of reinfection after prosthesis removal and antibiotic bone cement spacer implantation for the treatment of PJI. METHODS: Clinical data of 40 patients who underwent prosthesis removal and antibiotic bone cement spacer implantation for PJI after arthroplasty in our hospital from January 2013 to July 2019 were retrospectively analyzed. During the follow-up period of at least 2 years, 21 patients underwent complete two-stage revision after the removal of the antibiotic bone cement spacer, and 19 patients did not receive a new prosthesis due to other factors, such as reinfection or the patient's wishes, record the infection control of patients during the treatment. Reinfection after prosthesis removal and antibiotic bone cement spacer implantation was defined as failure of effective control of infection, symptoms of reinfection, requires increased antibiotic therapy or reoperation. Multivariate Cox proportional hazards model was used to analyze the risk factors associated with reinfection after prosthesis removal and antibiotic bone cement spacer implantation. RESULTS: Of the 40 patients, nine (22.5%) developed reinfection after prosthesis removal and antibiotic bone cement spacer implantation with a mean follow-up duration of 31 months, and multivariate analysis revealed that history of prior revision surgery (hazard ratio [HR] = 6.317, confidence interval [CI]: 1.495-26.700; p = 0.012) and presence of sinus tract before treatment (HR = 5.117, 95% CI: 1.199-21.828; p = 0.027) were independent risk factors for reinfection after prosthesis removal and antibiotic bone cement spacer implantation. CONCLUSION: History of prior revision surgery and presence of sinus tract are two independent risk factors for reinfection in patients with PJI treated with prosthesis removal and antibiotic bone cement spacer implantation.