External Validation of the Joint-Specific Bone Involvement, Antimicrobial Options, Coverage of the Soft Tissues, and Host Status (JS-BACH) Classification for Predicting Outcome in Periprosthetic Joint Infections: A Cohort of 653 Patients.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication in hip and knee joint arthroplasty. The "Joint-Specific Bone Involvement, Antimicrobial Options, Coverage of the Soft Tissues, and Host Status (JS-BACH)" classification system was developed in 2021 to stratify the complexity of PJI, and more importantly, to act as a tool to guide referrals to specialist centers. The "JS-BACH" classification has not been validated in an external cohort. This study aimed to do so using a large prospective cohort from Australia and New Zealand. METHODS: We applied the JS-BACH classification to the Prosthetic Joint Infection in Australia and New Zealand Observational (PIANO) cohort. This prospective study of newly diagnosed PJI collected 2-year outcome data from 653 participants enrolled in 27 hospitals. The definition of PJI treatment failure at 24 months was any of the following: death, clinical or microbiological signs of infection, destination prosthesis removed, or ongoing antibiotic use. Individual cases were classified as per JS-BACH into "1: uncomplicated" (n = 268), "2: complex" (n = 330), and "3: limited options" (n = 55). This cohort was similar to the original JS-BACH population in terms of baseline characteristics. However, there was a difference in complexity, with more debridement, antibiotics, and implant retention procedures, fewer revision procedures, and a higher proportion of uncomplicated patients in the PIANO cohort. RESULTS: The risk of treatment failure correlated strongly with the JS-BACH category, with odds ratios (95% confidence interval) for category 2 versus 1 of 1.75 (1.24 to 2.47) and for category 3 versus 1 of 7.12 (3.42 to 16.02). CONCLUSIONS: Despite the PIANO study population being less complicated than the original derivation cohort, the JS-BACH classification showed a clear association with treatment failure in this large external cohort.

The effect of iliotibial band surgery at the hip: a systematic review.

BACKGROUND: Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases. PURPOSE: The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery. METHODS: The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed. RESULTS: A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery. CONCLUSION: ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.

The value of sonication on orthopaedic implants in an everyday clinical setting - an exploratory study.

BACKGROUND: Sonication of removed orthopaedic implants in suspected implant-associated infections (IAI) is widely applied internationally. However, evaluation of the utility of sonication on all implants removed in everyday standard practice is scarce. This exploratory study was performed to evaluate the application of sonication fluid (SF) culture on removed orthopaedic implants, irrespective of the reason for removal. METHODS: Out of 100 removed orthopaedic implants collected between August 2019 and September 2020, 77 implants with availability of concurrent tissue culture samples were included in the study. Removed implants were categorized into a confirmed or suspected IAI group and a presumed aseptic group based on pre-operative diagnosis by the responsible surgeon. Implants were sonicated and SF culture performed under both aerobic and anaerobic conditions. The significance of all bacterial isolates was evaluated based on the CFU/mL cut-offs of the EBJIS guidelines, except for C. acnes where additional investigations were performed. RESULTS: The results of SF culture in the two groups were compared with their corresponding tissue cultures. Out of the 12 cases in the confirmed/suspected IAI group, SF culture was positive in 11 cases and had increased diagnostic yield in two (17%) cases compared to tissue culture. Increased diagnostic yield of SF compared to tissue culture was seen in seven (11%) of the 65 implants in the presumed aseptic group. If growth of Cutibacterium species isolates were interpreted based on EBJIS cut-off for SF culture instead of the study-specific criteria, then two isolates considered to represent infection might have been missed while three other isolates considered contaminants would have fallen under the 'infection confirmed' category in the EBJIS guidelines. CONCLUSION: Sonication with SF culture has increased diagnostic yield compared to tissue cultures in all implants irrespective of reason for removal. However, positive SF cultures with Cutibacterium species should always be interpreted with extreme care.

Limited clinical utility of a machine learning revision prediction model based on a national hip arthroscopy registry.

PURPOSE: Accurate prediction of outcome following hip arthroscopy is challenging and machine learning has the potential to improve our predictive capability. The purpose of this study was to determine if machine learning analysis of the Danish Hip Arthroscopy Registry (DHAR) can develop a clinically meaningful calculator for predicting the probability of a patient undergoing subsequent revision surgery following primary hip arthroscopy. METHODS: Machine learning analysis was performed on the DHAR. The primary outcome for the models was probability of revision hip arthroscopy within 1, 2, and/or 5 years after primary hip arthroscopy. Data were split randomly into training (75%) and test (25%) sets. Four models intended for these types of data were tested: Cox elastic net, random survival forest, gradient boosted regression (GBM), and super learner. These four models represent a range of approaches to statistical details like variable selection and model complexity. Model performance was assessed by calculating calibration and area under the curve (AUC). Analysis was performed using only variables available in the pre-operative clinical setting and then repeated to compare model performance using all variables available in the registry. RESULTS: In total, 5581 patients were included for analysis. Average follow-up time or time-to-revision was 4.25 years (± 2.51) years and overall revision rate was 11%. All four models were generally well calibrated and demonstrated concordance in the moderate range when restricted to only pre-operative variables (0.62-0.67), and when considering all variables available in the registry (0.63-0.66). The 95% confidence intervals for model concordance were wide for both analyses, ranging from a low of 0.53 to a high of 0.75, indicating uncertainty about the true accuracy of the models. CONCLUSION: The association between pre-surgical factors and outcome following hip arthroscopy is complex. Machine learning analysis of the DHAR produced a model capable of predicting revision surgery risk following primary hip arthroscopy that demonstrated moderate accuracy but likely limited clinical usefulness. Prediction accuracy would benefit from enhanced data quality within the registry and this preliminary study holds promise for future model generation as the DHAR matures. Ongoing collection of high-quality data by the DHAR should enable improved patient-specific outcome prediction that is generalisable across the population. LEVEL OF EVIDENCE: Level III.

Corrigendum: Risk of reoperation due to surgical site infection in 74,771 hip fracture patients: a Danish nationwide cohort study.

Corrigendum of Acta Orthop 2022; 93: 760-766. doi: https://doi.org/10.2340/17453674.2022.4580.

Risk of reoperation due to surgical site infection in 74,771 hip fracture patients: a Danish nationwide cohort study.

BACKGROUND AND PURPOSE: Surgical site infection (SSI) after hip fracture surgery is a feared condition. We examined the trend in incidence of reoperation due to SSI up to 1 year following hip fracture surgery from 2005 to 2016 and risk factors of SSI by age, sex, comorbidity, type of fracture, and surgery. PATIENTS AND METHODS: We conducted a population-based, nationwide cohort study using data from the Danish Multidisciplinary Hip Fracture Register (DMHFR). We included 74,771 patients aged 65 and up who underwent surgery from 2005 to 2016 for all types of hip fracture. We calculated net risk of reoperation using Kaplan­Meier method, and, with Cox regression, adjusted hazard ratios (HRs) with a 95% confidence interval (CI) for reoperation due to SSI. RESULTS: Overall, the 1-year net risk of reoperation due to SSI was 1.6%. The HR was higher for patients undergoing total/hemiarthroplasty surgery versus internal fixation (HR = 1.5; 95%CI 1.3­1.8) and lower for patients with per-/subtrochanteric fracture versus femoral neck fracture (HR = 0.6; CI 0.6­0.7). The risk of reoperation due to SSI decreased over time; HR was 0.7 (CI 0.5­0.8) for 2015­2016 compared with 2005­2006. Risk of reoperation decreased with increasing age; the HR was 0.8 (CI 0.7­1.0) in the more than 85-year-olds compared with 65­74-year-old patients. Charlson Comorbidity Index of ≥ 3 was associated with a higher risk of reoperation due to SSI, HR was 1.3 (CI 1.1­1.6). INTERPRETATION: The net risk of reoperations due to SSI in our study was lower than previously assumed. We identified several risk factors for increased risk of reoperation due to SSI, most noticeably treatment with arthroplasty vs. internal fixation, as well as younger age, high comorbidity burden, and femoral neck fracture diagnosis.

Unexpected positive cultures after revision shoulder arthroplasty: does it affect outcome?

BACKGROUND: Several studies have confirmed a high rate of unexpected positive cultures (UPCs) after presumably aseptic revisions of shoulder arthroplasties; however, the impact on the outcome is still unclear. The purpose of this prospective study is to compare the patient-reported outcomes of standard revisions with and without the emergence of UPCs. METHODS: During a 3-year period, we included all patients who were revised for reasons other than suspicion of infection from 2 orthopedic centers. Five biopsies were obtained from every revision, and only cultures with the same bacteria in at least 3 biopsy specimens were classified as UPCs. All patients were assessed using the Oxford Shoulder Score (OSS) and range of motion preoperatively and after at least a 2-year follow-up. RESULTS: In this study, 124 patients were included, with a median follow-up of 29 months (range 29-32), and UPCs emerged after 27 revisions (22%), with Cutibacterium acnes accounting for 67% (18/27). At baseline, the OSS was 22 in both the culture-negative and UPC groups (P = .46). Then, at follow-up, the OSS was 37 in the culture-negative group and 35 in the UPC group (P = .91). The forward elevation increased significantly by 44° and 41°, respectively, in the 2 groups, but no statistically significant difference between the culture-negative group and the UPC group was found (P = .66). In contrast, the external rotation was unchanged after the revision, and again, no difference in the change between the culture-negative and UPC groups (P = .54) was observed. Subgroup analyses stratified by different implant designs revealed equal patterns with no statistical differences in outcome. CONCLUSION: We did not find a difference in outcome after a presumed aseptic revision regardless of the emergence of UPCs. Similarly, we could not demonstrate that patients with UPCs presented with poorer function at baseline compared with culture-negative patients. The clinical relevance of UPCs thus requires further evaluation, especially in the case of C acnes as a potential pathogenic versus a merely colonizing microbe.

Percutaneous needle fasciotomy in Dupuytren contracture: a register-based, observational cohort study on complications in 3,331 treated fingers in 2,257 patients.

Background and purpose - Percutaneous needle fasciotomy (PNF) is a minimally invasive treatment option for Dupuytren contracture, which has gained momentum worldwide in recent years. However, evidence regarding safety and severe complications associated with PNF is sparse. Thus, we evaluated safety of a specific PNF method in the largest cohort reported in literature.Patients and methods - This is a single-center, register-based, observational study on PNF treatments between 2007 and 2015. The study cohort was identified by the Danish National Patient Registry, and diagnosis codes and procedure codes were used to identify potential severe postoperative complications such as: tendon rupture, nerve damage, infection, amputation, and reflex dystrophy for all index treatments. The Danish National Prescription Registry was used to identify non-hospital-treated infections. All index treatments and postoperative complications were verified by review of medical records.Results - 2,257 patients received PNF treatment of 3,331 treated finger rays. Median follow-up was 7.2 years (interquartile range: 4.9-9.5 years, range 1-12 years). 4 patients sustained flexor tendon rupture. 1 patient had digital nerve damage. 2 patients had an infection treated in hospital, while 31 patients received antibiotics in the primary sector for an infection or based on suspicion of an infection after PNF. None of the infections required surgical intervention. No finger amputations or ipsilateral upper limb reflex dystrophy cases were registered in relation to the procedure.Interpretation - Percutaneous needle fasciotomy for Dupuytren contracture is a safe procedure with a low rate of severe postoperative complications when a specific PNF method is applied.

Labeled white blood cell/bone marrow single-photon emission computed tomography with computed tomography fails in diagnosing chronic periprosthetic shoulder joint infection.

BACKGROUND: Shoulder periprosthetic joint infections (PJI) caused by low-virulent bacteria pose a diagnostic challenge. Combined labeled leukocyte (WBC) and technetium 99m sulfur colloid bone marrow imaging (WBC/BM) is considered the radionuclide imaging gold standard for diagnosing lower limb PJI. However, it is laborious and expensive to perform, and documentation on shoulder arthroplasties is lacking. This study investigated WBC/BM single-photon emission computed tomography-computed tomography diagnostic performance in shoulder PJI. METHOD: All patients with a failed arthroplasty referred to a highly specialized shoulder department were scheduled for a diagnostic program including a WBC/BM. If an arthroplasty was revised, biopsy specimens were obtained and cultured for 14 days. The diagnostic performance of WBC/BM imaging was determined using biopsy specimens as a reference. RESULTS: Of the 49 patients who underwent a WBC/BM scan, 29 (59%) were revised. Infection was present in 11 patients, in whom 2 WBC/BM scans were true positive. The WBC/BM scan in 9 patients was false negative. The remaining 18 patients all had a true negative WBC/BM scan. WBC/BM showed a sensitivity 0.18 (95% confidence interval [CI], 0.00-0.41) and specificity 1.00 (95% CI, 1.00-1.00) in detecting shoulder PJI. The positive predictive value was 1.00 (95% CI, 1.00-1.00), and negative predictive value was 0.67 (95% CI, 0.49-0.84). No patients infected with Cutibacterium (formerly Propionibacterium) acnes resulted in a positive WBC/BM, nor had they preoperative or perioperative signs of infection. CONCLUSION: A positive WBC/BM was found only in patients with obvious PJI. Hence, the scan added nothing to the preoperative diagnosis. The WBC/BM single-photon emission computed tomography-computed tomography scan cannot be recommended as a screening procedure when evaluating failed shoulder arthroplasties for possible infection.

Improved Patient-Reported Quality of Life and Hip Function After Cementless 1-Stage Revision of Chronic Periprosthetic Hip Joint Infection.

BACKGROUND: Limited information is available on health-related quality of life (HRQoL) and patient-reported hip function following treatment for a chronic periprosthetic hip joint infection. The purpose of this study is to evaluate changes in HRQoL and patient-reported hip function 2 years following a cementless 1-stage revision for chronic periprosthetic hip joint infection. METHODS: Patients (n = 52) enrolled in a previously published clinical study on cementless 1-stage revision in chronic periprosthetic hip joint infection prospectively answered the EuroQol-5D, Short-Form Health Survey 36 (SF-36), and Oxford Hip Score preoperatively and at 3, 6, 12, and 24 months follow-up. Results were compared to age-matched and gender-matched population norm. RESULTS: A significant improvement in HRQoL and patient-reported hip function appeared in the first 3 months after surgery and reached a plateau after 6 months. The patients statistically reached age-matched and gender-matched population norm after 3 to 12 months follow-up on most items, except for Physical Functioning and Social Functioning on the SF-36. The largest effect sizes were found for Oxford Hip Score at 1.8 and for Role Limitation, Physical and Bodily Pain on the SF-36 at 1.5 and 1.6, respectively. CONCLUSION: Patients treated with a cementless 1-stage revision for chronic periprosthetic hip joint infection experienced a marked increase in HRQoL and patient-reported hip function, and matched population norms on many parameters.

Cementless One-Stage Revision in Chronic Periprosthetic Hip Joint Infection. Ninety-One Percent Infection Free Survival in 56 Patients at Minimum 2-Year Follow-Up.

BACKGROUND: Cementless 1-stage revision in chronic periprosthetic hip joint infections is limited evaluated. The purpose of this study was to evaluate a specific treatment protocol in this patient group. METHODS: The study was performed as a multicenter, proof-of-concept, observational study with prospective data collection. Patients were treated with a cementless 1-stage revision according to the CORIHA protocol between 2009 and 2014. Fifty-six patients, McPherson type III-A/B-1/2, were enrolled with a mean follow-up time from the CORIHA procedure of 4 years (minimum of 2 years). The primary outcome was re-revision performed due to infection and was evaluated by competing risk analysis, with death and aseptic revision as competing events. All-cause mortality was evaluated by Kaplan-Meier survival analysis. Oxford Hip Score (OHS) was used as disease-specific patient-reported outcome measure. RESULTS: The cumulative incidence of re-revision due to infection was 8.9% (confidence interval [CI] 3.2%-18.1%). The 1-year and 5-year survival incidence was 96% (CI 86%-99%) and 89% (CI 75%-95%). OHS at baseline was 19.9 (CI 17.3-22.6) and at 24-month follow-up 35.1 (CI 31.7-38.5). The mean change in OHS from baseline to 24-month follow-up was 11.8 points (CI 7.3; 16.3). Three patients had aseptic revision performed: two suffered periprosthetic fractures and one had stem subsidence. Failure analysis of the 5 reinfections did not detect a clear pattern as to the cause of failure. CONCLUSION: We found that cementless 1-stage revision in chronic periprosthetic hip joint infections has low reinfection rates in selected patients and may be applicable as a first-line treatment.

Open Surgery Versus Ultrasound-Guided Corticosteroid Injection for Trigger Finger: A Randomized Controlled Trial With 1-Year Follow-up.

PURPOSE: Trigger finger is a common condition with a lifetime prevalence of 2%. Corticosteroid injection is a treatment often considered as a first-line intervention with reported cure rates between 60% and 90% in observational cohorts. Nevertheless, open surgery remains the most effective treatment with reported cure rates near 100%. Head-to-head trials on these treatments are limited. We investigated the efficacy of open surgery compared with ultrasound-guided corticosteroid injections. METHODS: The study was performed as a single-center, randomized, controlled trial with a 1-year follow-up. A total of 165 patients received either open surgery (n = 81) or ultrasound-guided corticosteroid injection (n = 84). Follow-up was conducted at 3 and 12 months. If the finger had normal movement or normal movement with discomfort at latest follow-up, the outcome was considered a success. Secondary outcomes were postprocedural pain and complications. RESULTS: The groups were similar at baseline except for lower alcohol consumption in the open surgery group. At 3 months, 86% and 99% were successfully treated after corticosteroid injection and open surgery, respectively. At 12 months, 49% and 99% were considered successfully treated after corticosteroid injection and open surgery, respectively. The pain score at latest follow-up was significantly higher in the corticosteroid injection group. Complications after open surgery were more severe and included 3 superficial infections and 1 iatrogenic nerve lesion. After corticosteroid injection 11 patients experienced a steroid flare and 2 had fat necrosis at the site of injection. CONCLUSIONS: Open surgery is superior to ultrasound-guided corticosteroid injections. Complications after open surgery are more severe; this must be taken into account when advising patients with regard to treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Injectable Collagenase Versus Percutaneous Needle Fasciotomy for Dupuytren Contracture in Proximal Interphalangeal Joints: A Randomized Controlled Trial.

PURPOSE: Collagenase Clostridium histolyticum (CCH) injection was introduced commercially as a treatment for Dupuytren contracture following initial phase-3 investigations in 2009 with promising results. However, the efficacy of CCH has not been prospectively investigated in a direct comparison to other active treatments of Dupuytren contracture with more than 1-year follow-up, despite a wide and increasing clinical use. METHOD: In this prospective, independent, open-label, randomized controlled trial, (Clinicaltrials.gov; NCT 01538017), percutaneous needle fasciotomy (PNF) was directly compared with CCH. Fifty patients with primary isolated proximal interphalangeal joint Dupuytren contractures were enrolled and followed for 2 years. The primary outcome was clinical improvement defined as a reduction in contracture by 50% or more relative to baseline. Secondary outcomes included change in contracture, recurrence, adverse events, complications, and Disabilities of the Arm, Shoulder, and Hand questionnaire score. RESULTS: Clinical improvement at 2 years was maintained in 7% of CCH patients (2 of 29) and 29% of PNF patients (6 of 21). Collagenase Clostridium histolyticum led to more, mainly transient, complications, in 93% of patients versus 24% of the patients treated with PNF. No other differences were observed. CONCLUSIONS: This study provides evidence that CCH is not superior to PNF in the treatment of isolated proximal interphalangeal joint Dupuytren contracture regarding clinical outcome, and it led to more complications than PNF. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Open surgical repair of hip abductor tendon tears.

INTRODUCTION: Tendinopathy and tendon tears of the gluteus medius and/or minimus (GMM) insertion at the greater trochanter are increasingly recognised internationally as a cause of recalcitrant lateral hip pain (LHP). The purpose of this study was to report the first Danish results of open surgical repair of GMM tears in female patients. METHODS: In this retrospective observational study, we included 67 women (68 hips) with a mean (95% confidence interval (CI)) age of 59 (56-61) years who underwent open GMM repair between September 2018 and June 2022. All cases had magnetic resonance imaging before surgery. Pre-, three- and 12-month post-operative testing included LHP (numerical rating scale 0-10), Copenhagen Hip and Groin Outcome Score (HAGOS), Oxford Hip Score (OHS), the EuroQol-Visual Analogue Scale (EQ-VAS) and the Global Rating of Change score (GROC). Responses on GROC were considered successful if patients scored "moderately better" to "very much better". Function of the lower limbs was assessed by the 30-second Chair-Stand-Test (CST). RESULTS: From pre-testing to 12-month follow-up, LHP at rest and during activity decreased significantly, all HAGOS subgroups improved by 27-35 points, the OHS improved from 22 to 35 points, the EQ-VAS improved from 52 to 72 points and the mean (95% CI) number of repetitions in the CST improved by 2.4 (1.4-3.3). Success on the GROC was reported by 79% of the patients. CONCLUSION: Open surgical repair of GMM tendon tears in women produced statistically significant improvements in patient-reported outcomes at one-year follow-up. FUNDING: None. TRIAL REGISTRATION: Not relevant.

Shotgun sequencing of sonication fluid for the diagnosis of orthopaedic implant-associated infections with Cutibacterium acnes as suspected causative agent.

Orthopaedic implant-associated infections (OIAIs) due to Cutibacterium acnes can be difficult to diagnose. The aim of this pilot study was to determine if metagenomic next-generation sequencing (mNGS) can provide additional information to improve the diagnosis of C. acnes OIAIs. mNGS was performed on sonication fluid (SF) specimens derived from 24 implants. These were divided into three groups, based on culture results: group I, culture-negative (n = 4); group II, culture-positive for C. acnes (n = 10); and group III, culture-positive for other bacteria (n = 10). In group I, sequence reads from C. acnes were detected in only one SF sample, originating from a suspected case of OIAIs, which was SF and tissue culture-negative. In group II, C. acnes sequences were detected in 7/10 samples. In group III, C. acnes sequence reads were found in 5/10 samples, in addition to sequence reads that matched the bacterial species identified by culture. These samples could represent polymicrobial infections that were missed by culture. Taken together, mNGS was able to detect C. acnes DNA in more samples compared to culture and could be used to identify cases of suspected C. acnes OIAIs, in particular regarding possible polymicrobial infections, where the growth of C. acnes might be compromised due to a fast-growing bacterial species. However, since SF specimens are usually low-biomass samples, mNGS is prone to DNA contamination, possibly introduced during DNA extraction or sequencing procedures. Thus, it is advisable to set a sequence read count threshold, taking into account project- and NGS-specific criteria.

Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial].

INTRODUCTION: A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI. METHODS AND ANALYSIS: The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included. INCLUSION CRITERIA: age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future. ETHICS AND DISSEMINATION: This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences. TRIAL REGISTRATION NUMBER: NCT05530551.

Early periprosthetic hip joint infection managed by cementless one-stage revision - a case series.

Background: Early periprosthetic hip joint infection (PJI) is traditionally treated with debridement, antibiotics, and implant retention (DAIR). However, infection control rates after DAIR-treated periprosthetic hip joint infection do not exceed 77 %. Cementless one-stage revision of chronic PJI by the Cementless One-stage Revision of Infected Hip Arthroplasty (CORIHA) protocol has been evaluated positively with a 91 % success rate. We wanted to evaluate the effectiveness of cementless one-stage revision following the CORIHA protocol for early PJI in elective primary total hip arthroplasty, regarding risk of re-operation with exchange of implants. Methods: We identified 18 patients in our center with early ( ≤ 6 -week postoperative) PJI after primary total hip arthroplasty (THA) treated with one-stage cementless revision in the period January 2012-March 2018. Treatment followed the CORIHA protocol. Primary outcome was retention of implants at the most recent follow-up. Patients were followed for a minimum of 3 years. Results: Mean follow-up time was 60 months (39-105). All patients retained their implants, but two required superficial soft tissue debridement due to persistent wound seepage. Conclusion: Cementless one-stage revision appears to be an effective treatment of early PJI after primary THA and at least an equal choice of treatment compared with DAIR. Whether the potential benefit of a lower re-revision rate for postoperative PJI outweighs the increased surgical complexity of the CORIHA procedure needs further evaluation.

Low prevalence of trochanteric bursitis in patients with refractory lateral hip pain.

INTRODUCTION: Bursitis at the greater trochanter has historically been identified as a major pain generator in patients with lateral hip pain (LHP). We believe that hip abductor tendon pathology (HATP) plays an important and overlooked role in LHP. The purpose of this study was to evaluate the presence of isolated trochanteric bursitis on MRI in patients with refractory LHP. METHODS: The MRIs of 120 patients with LHP (94% women, median age 54 years) performed at our orthopaedic outpatient clinic between 2017 and 2020 were evaluated by two raters for trochanter-related pathologies, including HATP and bursitis. RESULTS: Two (2%) patients were registered with greater trochanteric bursitis with no relevant HATP, 30 (25%) patients had elements of inflammation (high-intensity signals) in the greater trochanteric bursa with relevant HATP. Five (4%) patients had relevant HATP with bursitis in the sub-gluteus minimus bursa with no bursitis in the greater trochanteric bursa. The remaining 83 (69%) patients had no sign of trochanter-related bursitis. CONCLUSION: Isolated trochanteric bursitis as the cause of refractory LHP appears to be rare. We believe that the presence of HATP in LHP has been severely underestimated and a shift in focus towards treatment of these structures is necessary. FUNDING: none. TRIAL REGISTRATION: According to current national legislation, no formal ethical approval was required for this study. The National Data Protection Agency approved the study (1-16-02-124-19).

[Traumatic rupture of the gluteus minimus tendon].

An acute isolated tear of the gluteus minimus tendon after a traumatic event is very uncommon, and only a few cases have been reported worldwide. We present a case report of a 43-year-old woman with lateral hip pain after a scooter accident. Prior to the accident, she had no hip pain. Magnetic resonance imaging showed rupture of the gluteus minimus tendon attachment to the trochanter major. The patient underwent operative repair after non-surgical treatment had been attempted. The surgery was successful, and the patient fully recovered without any hip pain.