Treatment Outcomes of Fungal Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) continues to challenge surgeons and patients. The burden of fungal organisms may represent approximately 1% of all PJI. Additionally, fungal PJI is difficult to treat. Most available case series are small and report poor success rates. Fungi are opportunistic pathogens and patients who have fungal PJI are believed to be immunocompromised. Additionally, fungal biofilms are more complex than those formed by other pathogens and confer additional drug resistance. Due to these factors, treatment failure is common. METHODS: A retrospective review of our institutional registry was performed to identify patients treated for fungal PJI. There were 49 patients identified with 8 excluded for not having follow-up, which left 22 knees and 19 hips for analyses. Demographics, clinical characteristics, and surgical details were collected. The primary outcome was failure defined as reoperation for infection following the index surgery for fungal PJI within 1 year of the index surgery. RESULTS: Failure occurred in 10 of 19 knees and 11 of the 22 hips. A higher proportion of patients who have extremity grade C failed treatment, and every patient who failed was host grade 2 or 3. The average number of prior surgeries and time from resection to reimplantation were similar between groups. CONCLUSION: To our knowledge, this represents the largest cohort of fungal PJIs reported in the literature to date. This data supports other literature in that failure rates were high. More study is needed to further understand this entity and improve care for these patients.

Does Treatment at a Specialized Prosthetic Joint Infection Center Improve the Rate of Reimplantation.

BACKGROUND: Two-stage exchange arthroplasty is currently the preferred treatment method for periprosthetic joint infection (PJI). The effectiveness of this strategy in returning patients to premorbid function has recently been challenged. In a review of 18,535 PJI knee patients, 38% did not undergo reimplantation. In another review of 18,156 hip and knee PJI patients, 43% did not undergo reimplantation. These disturbing statistics led us to ask whether treatment at a specialized PJI center could improve the rate of reimplantation compared to the previously noted studies from large national administrative databases. METHODS: A retrospective review of our registry was performed to identify 390 patients who underwent a two-stage exchange after total knee arthroplasty and total hip arthroplasty who had a confirmed chronic bacterial PJI, defined by Musculoskeletal Infection Society criteria, from January 2010 through December 2019. Variables included number of joints resected, number reimplanted, and the number not reimplanted. RESULTS: Of the 390 patients undergoing 2-stage treatment, 386 of 390 (99%) were reimplanted and 4 of 390 (1%) were not reimplanted due to medical issues. CONCLUSION: We have shown that 2-stage treatment at a PJI center significantly improves the rate of reimplantation. A specialized PJI center with experienced revision surgeons doing high volume infection procedures complemented by infectious disease and medical consultants familiar with the special needs of PJI patients may be advantageous. A national network of such centers may have the ability to improve outcomes, standardize treatment protocols, and allow for collaborative research.

High Rate of Intramedullary Canal Culture Positivity in Total Knee Arthroplasty Resection for Prosthetic Joint Infection.

BACKGROUND: Periprosthetic infection is a devastating complication following total knee arthroplasty. A 2-stage protocol often includes an interim antibiotic spacer with intramedullary (IM) dowels. However, the necessity of IM dowels has recently been challenged. Specifically, the data supporting bacterial colonization of the IM canal are limited and controversial. The purpose of this study was to identify the rate of positive IM cultures during resection arthroplasty in periprosthetic knee infection. METHODS: A total of 66 IM diaphyseal cultures were taken during resection arthroplasty from 34 patients diagnosed with periprosthetic knee infection. These IM cultures were taken from the femoral and tibial canals using separate sterile instruments. All patients had infected primary total knee arthroplasty implants at the time of resection. RESULTS: Thirty one percent (n = 21) of IM canal cultures in this study were positive from either the tibial or the femoral diaphysis at the time of resection arthroplasty. There were 18 of 21 (86%) of the positive IM canal cultures with concordant intraoperative joint cultures where the IM cultures matched the intraarticular cultures. CONCLUSION: With a 31% positive IM canal culture rate, this study confirms the logic of using IM dowels with an antibiotic spacer to treat periprosthetic knee infection. Since the failure of a 2-stage reimplantation is catastrophic, any attempt to provide additional local antibiotic delivery seems warranted. Since nearly one-third of our patients had positive IM cultures, this simple addition to an antibiotic spacer has the potential to improve 2-stage results. Claims supporting the elimination of IM dowels during resection arthroplasty seem ill-advised.

Hypoalbuminemia Predicts Failure of Two-Stage Exchange for Chronic Periprosthetic Joint Infection of the Hip and Knee.

BACKGROUND: Nutritionally compromized patients, with preoperative serum albumin (SAB) < 3.5g/dL, are at higher risk for periprosthetic joint infection (PJI) in total joint arthroplasty. The relationship between nutritional and PJI treatment success is unknown. The purpose of this study was to examine the relationship between preresection nutrition and success after first-stage resection in planned two-stage exchange for PJI. METHODS: A retrospective review was performed on 418 patients who had first-stage resection of a planned two-stage exchange for chronic hip or knee PJI between 2014 and 2018. A total of 157 patients (58 hips and 99 knees) were included who completed first stage, had available preop SAB and had a 2-year follow-up. Failure was defined as persistent infection or repeat surgery for infection after resection. Demographic and surgical data were abstracted and analyzed. RESULTS: Among knee patients with preop SAB >3.5 g/dL, the failure rate was 32% (15 of 47) versus a 48% (25 of 40) failure rate when SAB <3.5 g/dL (P = .10). Similarly, the failure rate among hip patients with preop SAB >3.5 g/dL versus 12.5% (3 of 24) versus 44% (15 of 34) for hip patients with SAB <3.5 g/dL (P = .01). Multivariable regression results indicated that patients with SAB< 3.5 g/dL (P = .0143) and Musculoskeletal Infection Society host type C (P = .0316) were at an increased risk of failure. CONCLUSION: Low preoperative SAB and Musculoskeletal Infection Societyhost type-C are independent risk factors for failure following first-stage resection in planned two-stage exchange for PJI. Efforts to nutritionally optimize PJI patients, when possible, may improve the outcome of two-stage exchange.

Total Knee Arthroplasty following Knee Arthroscopy in Patients over 50.

The purpose of this study was to evaluate the conversion rate of knee arthroscopy to ipsilateral total knee arthroplasty (TKA) within 2 years in patients aged 50 or older at the time of arthroscopy. The administrative database from a large, physician-owned orthopaedic practice (>100 surgeons) was queried to identify patients over the age of 50 who had undergone arthroscopic knee surgery between January 1, 2006 and January 2, 2015. The subset of patients who converted to TKA within 2 years after knee arthroscopy was identified and matched by age and sex to a control population that did not convert to TKA. Rates of conversion to TKA were calculated. Prearthroscopic digital radiographs were reviewed and Kellgren-Lawrence (KL) grades were compared among case and control populations. Univariable analyses and multivariable regression analysis were performed. Eight hundred seven of 16,061 (5.02%) patients aged 50 or older were converted to TKA within 2 years following ipsilateral knee arthroscopy. In univariable analysis, the rate of conversion to TKA in patients aged between 50 and 54 was 2.94%, compared with 4.44% in patients aged between 55 and 64, and 8.32% in patients 65 or older (p < 0.0001). Female sex was associated with a higher rate of conversion to TKA in univariable analysis (5.93 vs. 4.02% in males, p < 0.0001). KL grades were higher among patients who converted to TKA compared with those who did not (p < 0.0001). In a multivariable regression model controlling for age, sex, and KL grade, only increased KL grade was associated with increased odds of conversion to TKA. In the appropriately selected older patient, the risk of conversion to TKA within 2 years of knee arthroscopy is low (∼5%). Patients with KL grade 2 or higher at the time of arthroscopy should be counseled on the increased odds of early conversion to TKA.

Polymicrobial Colonization of Prosthetic Joint Infections Treated With Open Wound Management.

BACKGROUND: Open wound management in prosthetic joint infection (PJI) patients has been used in problematic dehisced wounds hoping to stimulate granulation tissue and closure. However, infections that start as a monomicrobial PJI can become polymicrobial with resultant worse outcomes following open wound management. This study assessed the relationship between open wound management and the development of polymicrobial periprosthetic joint infections. METHODS: We reviewed patients referred with a synovial cutaneous fistula. Patients with an open wound measuring less than 2 cm and less than two weeks of open wound management were excluded. Variables included original organisms cultured, type and length of open wound management, and organisms cultured at the time of revision infection surgery. RESULTS: Of the 65 patients with a previous monomicrobial infection treated with open wound management, 22/65 (34%) progressed to a polymicrobial infection. Thirty (46%) wounds were packed open with gauze, 20 (31%) were managed with negative pressure wound therapy, and 15 (23%) had surface dressings only. Of the 22 patients who converted to a polymicrobial infection, only 10 (45%) were infection free at follow-up. In contrast, 30 of 43 patients (70%) whose infections remained monomicrobial were infection free at follow-up. CONCLUSION: Open wound management can lead to conversion from a monomicrobial to a polymicrobial PJI, a rate of 34% in this series. Open prosthetic wound management should be discontinued for a fear of converting a monomicrobial infection to a difficult to treat polymicrobial infection. Surgeons must be prudent in the use of open wound management. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series.

High-Dose Antibiotic Cement Spacers Independently Increase the Risk of Acute Kidney Injury in Revision for Periprosthetic Joint Infection: A Prospective Randomized Controlled Clinical Trial.

BACKGROUND: Standard treatment for periprosthetic joint infection (PJI) involves 2-stage exchange with placement of an antibiotic-impregnated cement spacer (ACS). Conflicting evidence exists on the role of ACS in development of acute kidney injury (AKI) after first-stage surgery. In this randomized clinical trial, we aimed to compare the incidence of AKI between the first-stage of a planned 2-stage exchange vs 1-stage exchange. This study design isolates the effect of the ACS in otherwise identical treatment groups. METHODS: The primary outcome variable was AKI, defined as a creatinine ≥1.5 times baseline or an increase of ≥0.3 mg/dL. Risk factors for AKI were evaluated using bivariate statistical tests and multivariable logistic regression. RESULTS: Patients who underwent the first stage of a planned 2-stage exchange were significantly more likely to develop AKI compared with the 1-stage exchange group (15 [22.7%] vs 4 [6.6%], P = .011). On multivariable regression analysis, ACS placement (odds ratio 7.48, 95% confidence limit 1.77-31.56) and chronic kidney disease (odds ratio 3.84, 95% confidence limit 1.22-12.08) were independent risk factors for AKI. CONCLUSION: Our study provides evidence that high-dose antibiotic cement spacers for treatment of PJI are an independent risk factor for AKI. Therefore, efforts to minimize nephrotoxicity should be employed in revision for PJI when possible.

Long Term Results of Two-Stage Revision for Chronic Periprosthetic Knee Infection: A Multicenter Study.

BACKGROUND: Long-term reinfection and mortality rates and clinical outcomes with sufficient subject numbers remain limited for patients undergoing two-stage exchange arthroplasty for chronic periprosthetic knee infections. The purpose of this study was to determine the long-term reinfection, complication, and mortality following reimplantation for two-stage exchange following knee arthroplasty. METHODS: Retrospective review of 178 patients who underwent two-stage exchange knee arthroplasty for chronic PJI at three large tertiary referral institutions with an average of 6.63-year follow-up from reimplantation from 1990 to 2015. Rates of reinfection, mortality, and all-cause revision were calculated along with the cumulative incidence of reinfection with death as a competing factor. Risk factors for reinfection were determined using Cox multivariate regression analysis. RESULTS: Overall rate of infection eradication was 85.41%, with a mortality rate of 30.33%. Patients with minimum 5-year follow-up (n = 118, average 8.32 years) had an infection eradication rate of 88.98%, with a mortality rate of 33.05%. CONCLUSION: This is a large series with long-term follow-up evaluating outcomes of two-stage exchange knee arthroplasty resulting in adequate infection eradication and high mortality. Results were maintained at longer follow-up. This technique should be considered in patients with chronic PJI; however, realistic expectations regarding long-term outcomes must be discussed with patients.

Survivorship and Radiographic Evaluation of Metaphyseal Cones With Short Cemented Stems in Revision Total Knee Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate the survivorship and radiographic outcomes of a single design of metaphyseal cone used in conjunction with short cemented stems. METHODS: A retrospective analysis was conducted of revision total knee arthroplasty (rTKA) patients (June 2015 to December 2017) using porous titanium femoral or tibial cones in conjunction with short cemented stems (50-75 mm). Minimum follow-up was 2 years. Survivorship, complications, and a modified Knee Society Radiographic score were analyzed. RESULTS: Forty-nine rTKAs were included in the study (12 femoral cones, 48 tibial cones). Varus-valgus constraint was used in 28 (57%) and a hinged bearing was used in 3 (6%) of these constructs. The majority were index rTKAs of primary components (86%), performed for aseptic loosening (51%) and reimplantation following staged treatment for infection (37%). Median follow-up was 39 months (range 25-58). Using a modified Knee Society Radiographic score, all constructs were classified as stable. Postoperatively, 4 rTKAs were complicated by recurrent infection (8%), periprosthetic fracture 2 (4%), and superficial wound infection 1 (2%). Seven rTKAs (14%) required reoperation. The majority of reoperations (4 rTKAs) were debridement and irrigation with implant retention for infection. Metaphyseal cone constructs with short cemented stems demonstrated 100% survivorship free of revision for aseptic loosening without evidence of radiographic loosening in any case. CONCLUSION: Our results demonstrate excellent outcomes with the use of metaphyseal cones with short cemented stems at mid-term follow-up. This construct avoids the use of long-stem fixation with the associated extraction difficulty, end of stem pain, and potential for malposition at the joint line. LEVEL OF EVIDENCE: IV, Case Series.

Do Pre-Reimplantation Erythrocyte Sedimentation Rate/C-Reactive Protein Cutoffs Guide Decision-Making in Prosthetic Joint Infection? Are We Flying Blind?

BACKGROUND: Two-stage exchange is a commonly used approach for treating chronic periprosthetic joint infections (PJI). A pre-reimplantation threshold value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to determine infection eradication and the proper timing of reimplantation remains ill-defined. METHODS: We retrospectively reviewed 483 potential patients for eligibility. In total, 178 patients were excluded. In addition, 305 joints were eligible who underwent 2-stage revision for prosthetic hip or knee joint infection (PJI). Serum ESR and CRP were recorded at 8 weeks post resection prior to stage 2 reimplantation. ESR and CRP were analyzed with receiver operating characteristic curves (ROC) for response failure. RESULTS: In total, 252 patients had resections for chronic infections while 53 septic patients had resections for acute infections. Forty-one of 252 (16.3%) patients failed reimplantation. Median ESR at the time of reimplantation was 17 (normal less than 20 mm/h). Median CRP was 0.6 (normal less than 0.5 mg/dL). ROC plot for response failure in analyzing ESR found an area under the curve (AUC) of 0.47. ROC plot analyzing CRP found an AUC of 0.57. The ratio of ESR/CRP was also utilized and found an AUC of 0.60. All of the AUC data are in the "fail to discriminate category." CONCLUSION: Although improvements in serology can be somewhat reassuring, there are no statistically significant values of ESR or CRP that would predict failure of reimplantation in the 2-stage treatment of PJI. Because we are flying blind consideration should be made for mandatory pre-reimplantation aspirates. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series.

Lower Extremity Girth Does Not Predict Complications in TKA.

BACKGROUND: Obese patients have increased complications after total knee arthroplasty (TKA). A body mass index (BMI) cutoff of 40 is frequently used to determine eligibility for TKA. Patients with a BMI <40 and extremely large legs which may predispose them to complications are approved for surgery because they fall below this cutoff. Alternatively, patients with truncal obesity and a BMI >40 are accepted because they have thin legs. We sought to determine whether BMI or girth should be used to determine eligibility. METHODS: 453 patients who underwent TKA were included. A lower extremity girth (LEG) ratio was calculated dividing the width of the soft tissue envelope by bone width on lateral radiographs. Receiver operator curves were generated to predict 90-day complications. RESULTS: There was no difference in median LEG ratio between patients with or without a complication (P = .08). Receiver operator curves indicated that size of the soft tissue envelope had no utility in predicting complications. There was no correlation between LEG ratio and specific complications such as infection, malalignment, or wound complications. Using a LEG ratio threshold of 4.834, the sensitivity and specificity for predicting complications were 48% and 64%, respectively. The median BMI for patients with no complication was 32.3 and 35 for patients with a complication (P = .07). CONCLUSION: Complications are not necessarily associated with size of the soft tissue envelope in TKA.Decisions concerning TKA should not be made solely on the size of a patient's leg. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Inflation-Adjusted Medicare Reimbursement for Revision Hip Arthroplasty: Study Showing Significant Decrease from 2002 to 2019.

BACKGROUND: Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures. METHODS: The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement. RESULTS: Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p < 0.00001). CONCLUSIONS: Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level. LEVEL OF EVIDENCE: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can an outpatient risk assessment tool predict who needs postoperative haemoglobin monitoring?

AIMS: Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement. METHODS: We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score. RESULTS: A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold. CONCLUSION: Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial cost savings in the era of cost containment. Cite this article: Bone Joint J 2021;103-B(1):65-70.

The Importance of Appropriate Incision Choice in Conversion Total Knee Arthroplasty.

When faced with the necessity of surgery in a previously operated knee, pre-operative planning and understanding of the vascular anatomy to the front of the knee is essential. Blood flow to the anterior aspect of the knee comes from medial to lateral. Therefore, in the case of multiple previous knee incisions the most lateral incision should always be chosen to avoid skin necrosis. The concept of a safe distance between incisions is inappropriate, risks extensive skin necrosis, and should be abandoned. (Journal of Surgical Orthopaedic Advances 30(4):253-255, 2021).

Medicare Physician Fee Reimbursement for Revision Total Knee Arthroplasty Has Not Kept Up with Inflation from 2002 to 2019.

BACKGROUND: As orthopaedic physician fees continue to come under scrutiny by the U.S. Centers for Medicare & Medicaid Services (CMS), there is a continued need to evaluate trends in reimbursement rates across contemporary time intervals. Although substantially lower work relative value units (RVUs) have been previously demonstrated for septic revision total knee arthroplasty (TKA) compared with aseptic revisions, to our knowledge, there has been no corresponding analysis comparing total physician fees. Therefore, the purpose of our study was to analyze temporal trends in Medicare physician fees for septic and aseptic revision TKAs. METHODS: Current Procedural Terminology (CPT) codes related to septic 1-stage and 2-stage revision TKAs and aseptic revision TKAs were categorized. From 2002 to 2019, the facility rates of physician fees associated with each CPT code were obtained from the CMS Physician Fee Schedule Look-Up Tool. Monetary data from Medicare Administrative Contractors at 85 locations were used to calculate nationally representative means. All total physician fee values were adjusted for inflation and were translated to 2019 U.S. dollars using Consumer Price Index data from the U.S. Bureau of Labor Statistics. Cumulative annual percentage changes and compound annual growth rates (CAGRs) were computed utilizing adjusted physician fee data. RESULTS: After adjusting for inflation, the total mean Medicare reimbursement (and standard deviation) for aseptic revision TKA decreased 24.83% ± 3.65% for 2-component revision and 24.21% ± 3.68% for 1-component revision. The mean septic revision TKA total Medicare reimbursement declined 23.29% ± 3.73% for explantation and 33.47% ± 3.24% for reimplantation. Both the dollar amount (p < 0.0001) and the percentage (p < 0.0001) of the total Medicare reimbursement decline for septic revision TKA were significantly greater than the decline for aseptic revision TKA. CONCLUSIONS: Septic revision TKAs have been devalued at a rate greater than their aseptic counterparts over the past 2 decades. Coupled with our findings, the increased resource utilization of septic revision TKAs may result in financial barriers for physicians and subsequently may reduce access to care for patients with periprosthetic joint infections. CLINICAL RELEVANCE: The devaluation of revision TKAs may result in reduced patient access to infection management at facilities unable to bear the financial burden of these procedures.

Radiologist Overreads of Intraoperative Radiographs-Value or Waste?

BACKGROUND: All aspects of the arthroplasty pathway must be scrutinized to maximize value and eliminate unnecessary cost. Radiology providers' contracts with hospitals often call for readings of all radiographs. This policy has little effect on patient care when intraoperative radiographs are taken and used to make real-time decisions. In order to determine the value of radiologist overreads, we asked 3 questions: what was the delay between the time an intraoperative radiograph was taken and time the report was generated, were the overreads accurate, and what is the associated cost? METHODS: Two hundred hip and knee radiograph reports generated over 6 months during 391 cases were reviewed. The time the report was dictated was compared to the time taken and time of surgery completion. To determine accuracy, each overread was rated as accurate or inaccurate. The cost of the overread was determined by multiplying the number of radiographs times the radiology fee less the technical fee. RESULTS: Median delay between taking the radiograph and filing the report was 45 minutes (range, 0-9778 minutes). Only 31.5% were filed before completion of the procedure. And 18.0% (36/200) were considered inaccurate despite lenient criteria. The reading fee for hip radiographs was $52.00, and for knee radiographs was $38.00, representing a total cost of $10,182 in our select series. This cost projects to $43,614 annually at our facility. CONCLUSION: Radiology overreads of intraoperative radiographs have no effect on real-time decision-making. In the era of value-based care, payors should stop paying for overreads and reimburse providers who actually read the films intraoperatively.

Irrigation and Debridement with Chronic Antibiotic Suppression Is as Effective as 2-Stage Exchange in Revision Total Knee Arthroplasty with Extensive Instrumentation.

BACKGROUND: Extraction of implants because of periprosthetic infection (PJI) following complex revision total knee arthroplasty (rTKA) with extensive instrumentation is a daunting undertaking for surgeon and patient alike. The purpose of the present study was to evaluate whether infections following complex rTKA are better treated with 2-stage exchange or irrigation and debridement (I&D) with modular component exchange and antibiotic suppression in terms of infection control, reoperation, and function. METHODS: We reviewed rTKAs that had been performed for the treatment of PJI from 2005 to 2016. Extensive instrumentation was defined as the presence ≥1 of the following: metaphyseal cones/sleeves, distal femoral replacement, periprosthetic fracture instrumentation, or fully cemented stems measuring >75 mm. Cases were categorized according to the initial treatment (I&D with antibiotic suppression or initiation of 2-stage exchange). RESULTS: Eighty-seven patients with PJI and extensive instrumentation were identified: 56 patients who were managed with I&D with suppression and 31 who were managed with the initiation of 2-stage exchange. The rate of success (defined as no reoperation for infection) was similar for the 2 groups (62.5% the I&D group compared with 67.7% for the 2-stage group; p = 0.62). The rate of mortality was also similar (39.3% for the I&D group compared with 38.7% for the 2-stage group; p = 0.96). Of the 31 patients in the 2-stage group, 18 (58.1%) underwent reimplantation with a revision replacement. Of those 18 patients, 13 were still infection-free at the time of the most recent follow-up; however, when the analysis was expanded to all 31 patients in the 2-stage group, only 13 (41.9%) both had a successful reimplantation and did not require additional surgery for infection. Nine (29.0%) of the 31 patients in the 2-stage group never underwent the second stage, and 4 (12.9%) of the 31 required arthrodesis at the second stage. In contrast, 35 (62.5%) of the 56 patients in the I&D group were successfully managed, without additional surgery for the treatment of infection. At the time of the latest follow-up (mean, 3.2 years; range, 2 to 13 years), more patients in the I&D group were ambulatory (76.8% in the I&D group compared with 54.8% in the 2-stage group; p = 0.05) and maintained a functional bending knee joint (85.7% in the I&D group compared with 45.2% in the 2-stage group; p < 0.001). CONCLUSIONS: In the treatment of periprosthetic infection of rTKA with extensive instrumentation, I&D with chronic antibiotic suppression was as effective as 2-stage exchange in terms of preventing reoperation for infection and was more effective in terms of maintaining function. These data apply to rTKA with extensive periarticular instrumentation and should not be extrapolated to primary or simple revision implants. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.