The Role of Three-Dimensional Custom Printing in Revision Total Hip Arthroplasty.

Acetabular revision accounts for approximately 18% of all total hip arthroplasty (THA) procedures. This was the third most common reason for THA revision in 2020. One of the unique challenges faced by reconstruction surgeons performing revision THAs is the issue of acetabular bone loss. The aim of this paper is to present the role of custom acetabular reconstruction with marked bone loss for undergoing revision THA, using a local case study as an example. We described utilization of custom components to address the highly complex cases with Paprosky classification of III and above. Recent studies have shown comparable clinical results to conventional methods and improvement of postoperative patient-rated outcome scores. However, larger clinical trials focusing on the long-term outcomes in comparison to off-the-shelf components in complex acetabular revisions would be of merit.

Differing Microorganism Profile in Early and Late Prosthetic Joint Infections Following Primary Total Knee Arthroplasty - Implications for Empiric Antibiotic Treatment.

BACKGROUND: Prosthetic joint infection (PJI) is the leading cause of revision following total knee arthroplasty (TKA). Prior to microorganism identification, the choice of the correct empiric antibiotics is critical to treatment success. This study aims to 1) compare the microorganism and resistance profile in early and late PJIs; 2) recommend appropriate empiric antibiotics. METHODS: A multicentre retrospective review was performed over a 15-year period. First episode PJIs were classified by both the Tsukayama Classification and Auckland Classification. For each PJI case, the causative organism and antibiotic sensitivity were recorded. RESULTS: Of eligible patients, 232 culture-positive PJI cases were included. Using either classification system, early PJIs (<4 weeks or <1 year since primary) were significantly more likely to be resistant and polymicrobial. The predominant organisms were coagulase-negative Staphylococci in early PJIs while Staphylococcus aureus was the most common in late PJIs. The distribution of gram-negative cases was higher in early Class-A than late Class-C PJIs (25% versus 6%, P = .004). Vancomycin provided significantly superior coverage when compared to Flucloxacillin for early infections, and addition of a gram-negative agent achieved coverage over 90% using both classification systems. CONCLUSION: Based on the microbiological pattern in Tsukayama criteria, Vancomycin with the consideration of Gram-negative agent should be considered for Class-A infections given the high proportion of resistant and polymicrobial cases. For Class-C infections, Cephazolin or Flucloxacillin is likely sufficient. We recommend antibiotics to be withheld in Class-B infections until cultures and sensitivities are known.

Success Rates of Debridement, Antibiotics, and Implant Retention in 230 Infected Total Knee Arthroplasties: Implications for Classification of Periprosthetic Joint Infection.

BACKGROUND: Prosthetic joint infection (PJI) is the most common cause of failure following total knee arthroplasty (TKA). This study aimed to determine the success of debridement, antibiotics, and implant retention (DAIR) in a large cohort of TKA PJIs and assess the utility of current classification systems in predicting DAIR outcomes in early postoperative, late hematogenous, and chronic PJIs. METHODS: In a multicenter review over 15 years, 230 patients underwent DAIR for first episode PJI following primary TKA. Patient demographics, disease and surgical factors, treatment regime, and outcomes were identified. Univariate and multivariate survival analyses were performed to identify factors associated with successful DAIR. Continuous variables with predictive value were further analyzed using receiver operating characteristic curves. The ability to predict DAIR outcomes of multiple classification systems was also assessed. RESULTS: Patients were followed for an average of 6.9 years. The overall success rate of DAIR was 53.9%. On receiver operating characteristic analysis, 3 months (area under the curve = 0.63) and 1-year age (area under the curve = 0.66) of implant cut-offs was similarly predictive of outcomes. On multivariate survival analysis, DAIR was successful in 64% of "early" PJIs (implant <1 year) vs 38% of "late hematogenous" PJIs (implant >1 year; odds ratio [OR] 1.78, P = .01). For late PJIs (implant >1 year), Staphylococcus aureus (OR 4.70, P < .001) and gram-negative infections (OR 2.56, P = .031) were risk factors for DAIR failure. CONCLUSION: DAIR has a high failure rate in all PJIs occurring more than a year post primary TKA, particularly when caused by S aureus or gram-negative bacteria. The age of implant is an important predictor of DAIR outcomes.

Failed Debridement and Implant Retention Does Not Compromise the Success of Subsequent Staged Revision in Infected Total Knee Arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) is the leading cause of early revisions after total knee arthroplasty. Debridement, antibiotics, and implant retention (DAIR) procedures are often the initial treatment for PJI. However, there is concern that failed DAIR undermines the future success of revision procedures. This study aims to investigate the impact of DAIR on the success of subsequent staged revisions for PJI. METHODS: A multicenter retrospective review was performed over a 15-year period. Treatment success was defined as implant retention without the use of long-term suppressive antibiotics. This was compared between patients who underwent a staged revision as the first procedure for PJI (staged-only) and patients who failed DAIR before staged revision (F-DAIR). Competing risk survival analysis was performed to compare the 2 groups and considered for patient demographics, American Society of Anesthesiologists score, organism type, body mass index, age of prosthesis, and duration of symptoms. RESULTS: Of 291 eligible patients, 63 underwent staged revision and 228 underwent DAIR as the first procedure for PJI. Of the 228 DAIR patients, 75 failed DAIR and underwent subsequent staged revision (F-DAIR). At mean follow-up of 6.2 years, the success rate was 72% in the F-DAIR group and 81% in the staged-only group. On survival analysis, there was no significant difference in subdistribution hazard ratio comparing the probability of failure (implant retention) in the 2 treatments groups (subdistribution hazard ratio = 0.72; 95% confidence interval 0.32-1.61; P = .42). CONCLUSION: This study suggested that a previously failed DAIR does not compromise the success rate of a subsequent staged revision.

The Impact of Sex on the Outcomes of Prosthetic Joint Infection Treatment with Debridement, Antibiotics and Implant Retention: A Systematic Review and Individual Patient Data Meta-analysis.

BACKGROUND: The influence of sex on the failure of débridement antibiotics and implant retention (DAIR) for treating prosthetic joint infection (PJI) is important for decision-making, patient counseling, and equitable health care. However, very few studies in the orthopaedic literature conduct sex-specific analyses. AIM: The primary aim was to determine whether sex influences treatment success after DAIR. METHODS: A systematic review and individual patient data (IPD) meta-analysis was conducted. MEDLINE (Ovid), EMBASE (Ovid), Web of Science, and Google Scholar were searched, and IPD was requested via e-mail. Patients who underwent DAIR after developing PJI within 12 months of a primary total hip or knee arthroplasty were included in the analysis. Treatment failure was defined by the Delphi International Consensus criteria. Adjusted odds ratios for treatment failure were calculated using a mixed-effects logistic regression. RESULTS: The study collected and analyzed IPD of 1,116 patients from 21 cohorts. The odds of treatment failure were 29% lower in women (odds ratio, 0.71; 95% CI 0.54 to 0.017; P = 0.017), after adjusting for duration of symptoms >7 days and Staphylococcus aureus infection (methicillin-susceptible Staphylococcus aureus or any infection with S aureus). None of the 64 studies included in the systematic review conducted a sex-specific analysis. CONCLUSION: For patients who developed a PJI within 1 year postsurgery, females have lower odds of DAIR failure than males. Other factors also have varying effects on outcome for men and women. It is essential to implement sex-specific analysis in orthopaedic research.

Glove change to reduce the risk of surgical site infection or prosthetic joint infection in arthroplasty surgeries: a systematic review.

BACKGROUND: Microbiological contamination of surgical gloves occurs during surgery, which may warrant glove change during orthopaedic surgeries. However, no systematic review of this topic has previously been published. Therefore, this review evaluated whether changing gloves during arthroplasty surgeries reduces the risk of surgical site infection/prosthetic joint infection (SSI/PJI) and the optimal frequency of glove change. METHODS: Search terms such as surgical gloves, surgical site infections, prosthesis-related infections, arthroplasty were used, including Medical Subject Headings terms. Of the 89 articles screened, 12 articles were included for qualitative synthesis. RESULTS: No studies measured the direct effect of glove change on PJI rate. Therefore, microbiological contamination and perforation rate of gloves were used as surrogate outcomes. Eight studies evaluated microbiological contamination of surgical gloves, with rates ranging from 3.4 to 30%. Five contamination studies recommended changing gloves after draping and before handling implants. One randomized controlled trial also recommended changing gloves at least once an hour regardless of surgical stages. Five studies recommended changing gloves to prevent perforation, with recommendations ranging from 20 to 90 min. Furthermore, one study advised change of gloves after resection of bone and before implantation. CONCLUSION: As microbiological contamination rates of gloves increase with duration of surgery, glove changes are recommended at least once per hour. Furthermore, gloves should be changed after draping, before handling implants and if visible perforation is seen to reduce contamination. Due to the lack of studies with SSI/PJI as primary outcomes, we cannot draw a definitive conclusion regarding the effectiveness of changing gloves in reducing the risk of SSI/PJI in arthroplasty.