General anesthesia might be associated with early periprosthetic joint infection: an observational study of 3,909 arthroplasties.

Background and purpose - Periprosthetic joint infection (PJI) remains a devastating complication following total knee or total hip arthroplasty (TKA/THA). Nowadays, many studies focus on preventive strategies regarding PJI; however, the potential role of anesthesia in the development of PJI remains unclear.Patients and methods - All consecutive patients undergoing elective primary unilateral TKA or THA from January 2014 through December 2017 were included. Exclusion criteria included femoral fractures as the indication for surgery and previously performed osteosynthesis or hardware removal on the affected joint. Age, sex, BMI, ASA classification, type of arthroplasty surgery, type of anesthesia, duration of surgery, smoking status, and intraoperative hypothermia were recorded. Propensity score-matched univariable logistic regression analysis was used to control for allocation bias.Results - 3,909 procedures consisting of 54% THAs and 46% TKAs were available for analysis. 42% arthroplasties were performed under general anesthesia and 58% under spinal anesthesia. Early PJIs were observed in 1.7% of the general anesthesia group and in 0.8% in the spinal anesthesia group. The multivariable logistic regression model demonstrated an odds ratio for PJI of 2.0 (95% CI 1.0-3.7) after general anesthesia relative to the propensity score-matched patients who received spinal anesthesia.Interpretation - These results suggest a potential association between general anesthesia and early PJI. Future research using large-scale data is required to further elucidate this clinically relevant association.

Clindamycin-rifampin combination therapy for staphylococcal periprosthetic joint infections: a retrospective observational study.

BACKGROUND: Staphylococcal species account for more than 50% of periprosthetic joint infections (PJI) and antimicrobial therapy with rifampin-based combination regimens has been shown effective. The present study evaluates the safety and efficacy of clindamycin in combination with rifampin for the management of staphylococcal PJI. METHODS: In this retrospective cohort study, patients were included who received clindamycin-rifampin combination therapy to treat a periprosthetic hip or knee infection by Staphylococcus aureus or coagulase-negative staphylococci. Patients were treated according to a standardized treatment algorithm and followed for a median of 54 months. Of the 36 patients with periprosthetic staphylococcal infections, 31 had an infection of the hip, and five had an infection of the knee. Eighteen patients underwent debridement and retention of the implant (DAIR) for an early infection, the other 18 patients underwent revision of loose components in presumed aseptic loosening with unexpected positive cultures. RESULTS: In this study, we report a success rate of 86%, with five recurrent/persistent PJI in 36 treated patients. Cure rate was 78% (14/18) in the DAIR patients and 94% (17/18) in the revision group. Five patients (14%) discontinued clindamycin-rifampin due to side effects. Of the 31 patients completing the clindamycin-rifampin regimen 29 patients (94%) were cured. CONCLUSION: Combined therapy with clindamycin and rifampin is a safe, well tolerated and effective regimen for the treatment of staphylococcal periprosthetic infection.

High complication rate after total knee and hip replacement due to perioperative bridging of anticoagulant therapy based on the 2012 ACCP guideline.

INTRODUCTION: An increasing amount of patients receiving total joint replacement require bridging of long-term anticoagulants. Guidelines, aimed at preventing complications, focus on thromboembolic events but not on bleeding complications. In this retrospective observational study, bleeding and thromboemoblic (TE) complications were evaluated in patients requiring perioperative heparin bridging of antithrombotic therapy during primary unilateral total hip or knee arthroplasty (THA and TKA). MATERIALS AND METHODS: Between January 2011 and June 2012, we identified all patients receiving low molecular weight heparin (LMWH) bridging during THA or TKA, according to our local protocol based on the ACCP guideline. Bleeding and TE complications, interventions and patient-related outcome measurements were used for evaluation. RESULTS: Among 972 patients 13 patients required bridging. Twelve patients (92%) experienced bleeding complications. An intervention was required in nine patients (69%). Seven patients received blood transfusion (54%). Nine patients (69%) developed a hematoma and two patients (15%) a periprosthetic joint infection. A total of five patients were re-admitted to hospital (39%) and the length of stay increased in all patients. No TE complications were observed in any of these patients. One year results of this patient group seem to be good. CONCLUSION: This study shows an alarmingly high complication rate in patients receiving LMWH bridging during elective TKA or THA surgery. All complications seem to be caused by, or secondary to bleeding. Patients need to be consulted about the risk of bleeding complications, and the risk of bleeding needs to be balanced over the risk of TE complications.

High incidence of postoperative hypothermia in total knee and total hip arthroplasty: a prospective observational study.

Hypothermia, a body temperature of <36°C, has been shown to increase cardiac mortality, the incidence of postoperative infections, and the length of hospitalization following general surgery. However, studies assessing the incidence of hypothermia during primary total hip and total knee arthroplasty (THA and TKA) have not previously been demonstrated. In this prospective observational study, incidence of hypothermia was measured among 672 patients (415 underwent THA and 257 TKA). The incidence of hypothermia for THA and TKA was 26.3 and 28.0%, respectively. In conclusion, over a quarter of patients in this study are exposed to hypothermia. This study highlights the requirement for interventions to prevent peri-operative hypothermia.

Effect of thermal reflective blanket placement on hypothermia in primary unilateral total hip or knee arthroplasty.

PURPOSE: Hypothermia in patients undergoing major clean surgery results in higher incidence of perioperative complications. The aim of this study was to evaluate whether the additional use of a thermal reflective blanket can prevent hypothermia in patients undergoing primary unilateral total hip or knee replacement surgery. DESIGN: A randomized, single-blinded study design was used. METHODS: A total of 58 patients were randomized, 29 received a thermal reflective blanket, and 29 did not. Outcome measures included core temperature, thermal comfort, and shivering. FINDINGS: The mean of the lowest core temperature was below 36°C in both the groups (35.9±0.4°C vs 35.8±0.4°C); thermal comfort and shivering were not significantly different between the groups. CONCLUSIONS: A thermal reflective blanket did not prevent hypothermia in this group of patients.

Clinical Outcome of Antibiotic Suppressive Therapy in Patients with a Prosthetic Joint Infection after Hip Replacement.

Introduction: In Specific cases, curative treatment of a prosthetic joint infection (PJI) cannot be accomplished due to the increased risk of major complications after prosthetic joint revision surgery. In these patients, antibiotic suppressive therapy (AST) is often used to control the infection. Aim: To describe the clinical outcome of patients with a PJI after hip replacement treated with AST. Methods: Patients in which AST for PJI was started between 2006 and 2013, were retrospectively included. Follow-up was continued until October 2018. AST has been defined as treatment with oral antibiotic therapy intended to suppress PJI. Treatment was considered successful in patients without reoperation for PJI or death related to PJI during follow-up. Results: Twenty-three patients were included. The most commonly used antibiotics were doxycycline (n=14) and cotrimoxazole (n=6). The mean duration of AST was 38 months (1-151 months). AST was considered successful in 13 patients (56.5%) after a median follow-up of 33 months. AST was least successful in PJI caused by S. aureus with 80% failures versus 33% in PJI caused by other microorganisms and in patients who had an antibiotic-free period before the start of AST with 83% failures. Two patients ended AST due to side effects. Conclusion: AST can be an alternative treatment in selected patients with a PJI after hip replacement. However, there is a persisting and considerable amount of failures, particularly in PJI caused by S. aureus and in patient with an antibiotic-free period before the start of AST.

Evaluation of early wound leakage as a risk factor for prosthetic joint infection.

BACKGROUND AND PURPOSE: Prosthetic joint infection (PJI) is a serious complication resulting from total knee arthroplasty (TKA) or total hip arthroplasty (THA). In this study, patients with a PJI are compared with patients with an uncomplicated postoperative course to identify relevant risk factors for PJI. METHODS: A matched case-control study was performed with patients undergoing fast-track, elective unilateral TKA or THA. The following data were collected: demographics, surgery-related characteristics (perioperative blood loss, use of cement, body temperature), and postoperative characteristics (hematoma formation, wound leakage, blood transfusion, length of stay [LOS]). CONCLUSIONS: When the PJI group was compared with the control group, there was significantly more wound leakage during hospital stay (88% vs. 36%, p = .001) and early wound dressing changes in the first 3 days after surgery (88% vs. 40%, p = .002). Hematoma formation was observed more in the PJI patients group (44% vs. 10%, p = .005). A trend test revealed a significant association between the total number of wound dressing changes and development of PJI (p < .001); 72% of PJI patients had a length of stay of ≥4 days compared with 34% of controls (odds ratio 10.5; 95% CI [2.1-52.3]; p = .004). IMPLICATIONS FOR PRACTICE: Early postoperative wound drainage and hematoma formation directly correlate with PJI. This resulted in a significantly higher number of dressing changes and longer LOS. The nurse practitioner has a central role in postoperative care and is the first to recognize signs of an adverse postoperative clinical course.

The incidence of mild hypothermia after total knee or hip arthroplasty: A study of 2600 patients.

Hypothermia is associated with a higher risk of perioperative complications and occurs frequently after total joint arthroplasty (TJA). The incidence of hypothermia following total joint arthroplasty was assessed with its risk factors and its correlation with PJI. Correlation of hypothermia with age, gender, BMI, type of arthroplasty surgery, type of anesthesia, operation time, blood loss, date of surgery and PJI was evaluated in 2600 patients. Female gender and spinal anesthesia increased the risk for hypothermia whereas an increased BMI and surgery duration correlated decreased the risk of hypothermia. The incidence of hypothermia decreased over time without a correlation with PJI.

Cement-within-cement revision of infected total hip replacement; disappointing results in 10 retrospective cases.

INTRODUCTION: This retrospective analysis evaluates 10 patients with a late infection of a cemented total hip arthroplasty (THA) treated with two-stage revision with retention of the original well-fixed femoral cement mantle. METHODS: Clinical, laboratory, and radiological outcomes were evaluated. The average age at the first-stage revision procedure was 61.5 years (range 38-80 y). The mean follow-up period was 26 months (range 5-54 m). RESULTS: Successful eradication of the primary microorganism was achieved in 2 patients. These patients had negative cultures at second stage and did not show any signs of infection during follow-up.The other 8 patients were considered as failures. In 3 patients, the femoral cement mantle was removed after the first stage due to recurrent infection in Girdlestone situation. In 2 patients, cultures showed the same micro-organism at first and second stage, treated with 3 months of antibiotics after second stage. 2 patients showed negative cultures at second stage but still had recurrent infection afterwards. These where treated with debridement and implant retention (DAIR) and 3 months of antibiotics. 1 patient was treated with suppressive antibiotics for persistent prosthetic joint infection after second stage, despite DAIR and therapeutic antibiotic treatment. CONCLUSIONS: Based on this study, results of two-stage revision with retention of femoral cement mantle are disappointing in treatment of infected THA. Therefore, more research is required to determine which patients are appropriate for cement-within-cement revision.

Antibiotic mixing through impacted bone grafts does not seem indicated in two-stage cemented hip revisions for septic loosening.

Impaction bone grafts (IBG) in two-stage revision for prosthetic hip infection (PHI) might be more susceptible for infection, therefore antibiotic mixing through these grafts has been suggested. However, outcomes have not been compared with IBG without antibiotics and no long-term results are available. Therefore, we evaluated long-term infection-free outcome after the use of IBG without antibiotic supplement in two-stage revision for PHI. Patients were divided into positive (group 1, n = 8) and negative (group 2, n = 28) cultures at re-implantation and followed up to 18 years after re-implantation. Five of 36 patients died from non-orthopaedic causes (median 37, range 24-149 months). Five patients had a re-operation not related to infection (median 39, range 7-140 months). These were censored in the Kaplan-Meier estimator at the last outpatient evaluation. We found an overall re-infection rate of 2.8% within two years, which matches comparative studies in which antibiotic impregnated bone grafts had been used. In group 1, there was one re-infection after 44 months. In group 2, all three infections occurred within 56 months with an estimated infection-free percentage at 10 years of 87% (95% CI 66-96). Follow-up should be extended beyond two years and randomised clinical trials are needed for further comparison with IBG impregnated with antibiotics.