What Is the Most Effective Treatment for Periprosthetic Joint Infection After Total Joint Arthroplasty in Patients with Rheumatoid Arthritis?: A Systematic Review.

BACKGROUND: Rheumatoid arthritis (RA) is a risk factor for periprosthetic joint infection (PJI) after total joint arthroplasty (TJA). The purpose of this study was to perform a systematic review comparing the failure rates of debridement, antibiotics, and implant retention (DAIR), one-stage exchange arthroplasty/revision (OSR), and 2-stage exchange arthroplasty/revision (TSR) for RA patients with PJI and identify risk factors in the RA population associated with increased treatment failure rate. METHODS: PubMed, Ovid MEDLINE, and Ovid Embase databases were screened with the terms "rheumatoid arthritis," "total joint arthroplasty," "prosthetic joint infection," and "treatment for PJI" on August 29, 2021. Four hundred ninety-one studies were screened, of which 86 were evaluated. The primary outcome evaluated was failure of surgical treatment for PJI. RESULTS: Ten retrospective cohort studies were included after full-text screening, yielding 401 patients with RA. Additional demographic and PJI management data were obtained for 149 patients. Patients with RA who underwent TSR demonstrated a lower failure rate (26.8%) than both DAIR (60.1%) and OSR (39.2%) (χ2 = 37.463, p < 0.00001). Patients with RA who underwent DAIR had a 2.27 (95% CI, 1.66-3.10) times higher risk of experiencing treatment failure than those who underwent TSR. Among risk factors, there was a significant difference in the C-reactive protein of patients who did vs. did not experience treatment failure (p = 0.02). CONCLUSION: TSR has a higher rate of success in the management of PJI patients with RA compared with DAIR and OSR. The complete removal of the infected prosthesis and delayed reimplantation may lower the treatment failure rate. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Are Accuracy Studies for Periprosthetic Joint Infection Diagnosis Inherently Flawed? And What to Do with Schrödinger's Hips? A Prospective Analysis of the Alpha Defensin Lateral-Flow Test in Chronic Painful Hip Arthroplasties.

Purpose: The most recent diagnostic criteria for periprosthetic joint infection (PJI) include the use of the alpha-defensin (AD) lateral-flow (LF) test, but hip and knee arthroplasties were usually combined in previous studies. This prospective study was designed to examine the accuracy of the AD-LF test for diagnosis of PJI in chronic painful total hip arthroplasties (THA). Materials and Methods: Patients with chronic painful hip arthroplasties were prospectively enrolled between March 2018 and May 2020. Exclusion criteria included acute PJI or an insufficient amount of synovial fluid. The modified Musculoskeletal Infection Society (MSIS) criteria were primarily used for PJI diagnosis. Fifty-seven patients were included in the analysis group. Revision surgery was not performed in 38 patients, for different reasons (clinical group); these patients remain "Schrödinger's hips": in such cases PJI cannot be excluded nor confirmed until you "open the box". Results: The result of the AD-LF test was positive in nine patients and negative in 48 patients. Six patients were diagnosed with PJI. AD-LF sensitivity (MSIS criteria) was 83% (95% confidence interval [CI] 36-100%) and specificity was 92% (95% CI 81-98%). The positive and negative predictive value were 56% and 98%, respectively. Conclusion: The AD test is useful in addition to the existing arsenal of diagnostic tools, and can be helpful in the decision-making process. Not all patients with chronical painful THA will undergo revision surgery. Consequently, in order to determine the reliable diagnostic accuracy of this test, future PJI diagnostic studies should include a second arm of "Schrödinger's hips".

The novel endolysin XZ.700 effectively treats MRSA biofilms in two biofilm models without showing toxicity on human bone cells in vitro.

In this in vitro study the effect of XZ.700, a new endolysin, on methicillin resistant Staphylococcus aureus (MRSA) biofilms grown on titanium was evaluated. Biofilms of S. aureus USA300 were grown statically and under flow, and treatment with XZ.700 was compared with povidone-iodine (PVP-I) and gentamicin. To evaluate the cytotoxic effects of XZ.700 and derived biofilm lysates, human osteocyte-like cells were exposed to biofilm supernatants, and metabolism and proliferation were quantified. XZ.700 showed a significant, concentration dependent reduction in biofilm viability, compared with carrier controls. Metabolism and proliferation of human osteocyte-like cells were not affected by XZ.700 or lysates, unlike PVP-I and gentamicin lysates which significantly inhibited proliferation. Using time-lapse microscopy, rapid biofilm killing and removal was observed for XZ.700. In comparison, PVP-I and gentamicin showed slower biofilm killing, with no apparent biofilm removal. In conclusion, XZ.700 reduced MRSA biofilms, especially under flow condition, without toxicity for surrounding bone cells.

Does the Alpha Defensin ELISA Test Perform Better Than the Alpha Defensin Lateral Flow Test for PJI Diagnosis? A Systematic Review and Meta-analysis of Prospective Studies.

BACKGROUND: Periprosthetic joint infection (PJI) following total joint arthroplasty is a serious complication that causes severe morbidity and adds a major financial burden to the healthcare system. Although there is plenty of research on the alpha-defensin (AD) test, a meta-analysis consisting of only prospective studies investigating AD's diagnostic efficacy has not been performed. Additionally, some important subgroups such as THA and TKA have not been separately analyzed, particularly regarding two commonly used versions of the AD test, the laboratory-based (ELISA) and lateral-flow (LF). QUESTIONS/PURPOSES: (1) Does the AD ELISA test perform better in the detection of PJI than the AD LF test, in terms of pooled sensitivity and specificity, when including prospective studies only? (2) Are there differences in sensitivity or specificity when using AD ELISA and AD LF tests for PJI diagnosis of THA or TKA PJI separately? METHODS: Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we included prospective studies describing the use of either AD test in the workup of pain after total joint arthroplasty (primary or revision, but not after resection arthroplasty). Fifteen studies (AD ELISA: 4; AD LF: 11) were included, with 1592 procedures. Subgroup data on THA and TKA could be retrieved for 1163 procedures (ELISA THA: 123; LF THA: 257; ELISA TKA: 228; LF TKA: 555). Studies not describing THA or TKA, those not using Musculoskeletal Infection Society (MSIS) criteria as the standard for determining the presence or absence of PJI, those not clearly reporting data for the AD test for the total cohort, and those describing data published in another study were excluded. Studies were not excluded based on follow-up duration; the MSIS criteria could be used within a few weeks, when test results were available. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 criteria. Study quality was generally good. The most frequent sources of bias were related to patient selection (such as unclear inclusion and exclusion criteria) and flow and timing (uncertainty in place and time of aspiration, for example). Heterogeneity was moderate to high; a bivariate random-effects model therefore was used. To answer both research questions, sensitivity and specificity were calculated for AD ELISA and LF test groups and THA and TKA subgroups, and were compared using z-test statistics and meta-regression analysis. RESULTS: No differences were found between the AD ELISA and the AD LF for PJI diagnosis in the pooled cohorts (THA and TKA combined), in terms of sensitivity (90% versus 86%; p = 0.43) and specificity (97% versus 96%; p = 0.39). Differences in sensitivity for PJI diagnosis were found between the THA and TKA groups for the AD ELISA test (70% versus 94%; p = 0.008); pooled AD LF test sensitivity did not differ between THA and TKA (80% versus 87%; p = 0.20). No differences in specificity were found in either subgroup. CONCLUSIONS: Both the AD ELISA and AD LF test can be used in clinical practice because both have high sensitivity and very high specificity for PJI diagnosis. The lower sensitivity found for diagnosis of PJI in THA for the AD ELISA test must be carefully interpreted because the pooled data were heterogenous and only two studies for this group were included. Future research should analyze TKAs and THAs separately to confirm or disprove this finding. LEVEL OF EVIDENCE: Level II diagnostic study.

Investigation of drug partition kinetics to fat in simulated fed state gastric conditions based on drug properties.

The presence of fat in the gastric environment can affect the pharmacokinetic behaviour of drugs with mechanisms which have not been yet fully understood. The objective of the current study was to assess the drug partition to the lipid part of the fed gastric content under different emulsification conditions, using in vitro discriminating setups. The model drugs used in the study were selected on the basis of different physicochemical properties (lipophilicity, ionization, molecular weight and aqueous solubility) and different food effect observed in in vivo human studies. Fed State Simulated Gastric Fluid prepared with skimmed milk (FeSSGFsk) and anhydrous milk fat were used as surrogates for the aqueous and fat portions of the fed gastric environment respectively. An optimized biphasic model was developed so as to predict the differences in partition rate constants to fat, for model drugs of a wide range of the properties mentioned above. The experimental data and the use of statistical analysis revealed that molecular weight, molecular weight and log D pH 5 interaction and negative food effect act as negative factors to the rate constants of fat partition, while absence of food effect and logD pH 5 interaction with aqueous solubility affect the rate constants of partition to fat favourably.

Good accuracy of the alpha-defensin lateral flow test for hip periprosthetic joint infection: A pilot study in a retrospective cohort of 52 patients.

BACKGROUND: The alpha-defensin lateral flow (ADLF) test is a new diagnostic tool for periprosthetic joint infection (PJI). Test accuracy for combined cohorts of hip and knee PJI has been reported to be good. AIM: To assess the accuracy of the ADLF test for hip PJI, and to compare three different diagnostic criteria for PJI. METHODS: A cohort of 52 patients was identified, with a painful or poorly functioning total hip- or hemi-arthroplasty, that underwent aspiration and a subsequent ADLF test. PJI was diagnosed with Musculoskeletal Infection Society (MSIS) criteria, and sensitivity, specificity, overall accuracy, positive predictive value and negative predictive value were calculated. Furthermore, test specifics were compared with the European Bone and Joint Infection Society (EBJIS) and 2018 International Consensus Meeting (ICM) criteria for PJI. RESULTS: Using MSIS criteria, sensitivity was 100% (CI: 54%-100%) and specificity was 89% (CI: 76%-96%). Six true positives and 5 false positives were found, including one case of metallosis. Using EBJIS criteria, more PJIs were found (11 vs 6), sensitivity was lower (71%, CI: 42%-92%) and specificity was higher (97%, CI: 86%-100%), with 4 false negatives and one false positive result. Using 2018 ICM criteria, sensitivity was 91% (62%-100%) and specificity 100% (91%-100%). The results in this cohort are comparable to previous studies. CONCLUSION: Overall test accuracy of the ADLF test was good in this cohort, with a sensitivity of 100% and specificity of 89%. Using different PJI definition criteria, sensitivity and specificity changed slightly but overall accuracy remained around 90%. Using the ADLF test in metallosis cases can result in false positive results and should be performed with caution.

Dissolution Testing in Drug Product Development: Workshop Summary Report.

This publication summarizes the proceedings and key outcomes of the first day ("Day 1") of the 3-day workshop on "Dissolution and Translational Modeling Strategies Enabling Patient-Centric Product Development." The overall aims of the workshop were to foster a productive dialog between industry and regulatory agencies and to discuss current strategies toward the development and implementation of clinically relevant dissolution specifications as an integral part of enhanced drug product understanding and effective drug product life-cycle management. The Day 1 podium presentations covered existing challenges and concerns for implementing highly valuable, yet often unique and novel experimental dissolution setups as quality control tools. In addition, several podium presentations highlighted opportunities to replace conventional dissolution testing with surrogate test methods to enable robust drug product and process understanding within the context of quality by design (QbD), new manufacturing technologies, and real-time release testing (RTRT). The topics covered on Day 1 laid the foundation for subsequent discussions which focused on the challenges related to establishing an in vitro-in vivo link and approaches for establishing clinically relevant drug product specifications which are becoming an expectation in regulatory submissions. Clarification of dissolution-related terminology used inconsistently among the scientific community, and the purpose of various testing approaches were key discussion topics of the Day 1 breakout sessions. The outcome of these discussions along with creative ways to overcome challenges related to bridging "exploratory dissolution approaches" with methods suitable for end-product control testing are captured within this report.

In Situ Stimulated Raman Scattering (SRS) Microscopy Study of the Dissolution of Sustained-Release Implant Formulation.

Localized drug delivery systems (DDSs) provide therapeutic levels of drug agent while mitigating side effects of systemic delivery. These systems offer controlled release over extended periods of time making them attractive therapies. Monitoring drug dissolution is vital for developing safe and effective means of drug delivery. Currently, dissolution characterization methods are limited to bulk analysis and cannot provide dissolution kinetics at high spatial resolution. However, dissolution rates of drug particles can be heterogeneous with influences from many factors. Insights into finer spatiotemporal dynamics of single particle dissolution could potentially improve pharmacokinetic modeling of dissolution for future drug development. In this work, we demonstrate high-resolution chemical mapping of entecavir, a hepatitis B antiviral drug, embedded in a slow release poly(d,l-lactic acid) formulation with stimulated Raman scattering (SRS) microscopy. By tracking the volume change of individual micron-sized drug particles within the polymer matrix, we establish an analytical protocol for quantitatively profiling dissolution of single crystalline particles in implant formulations in an in situ manner.

Impact of presence of excipients in drug analysis in fed-state gastric biorelevant media.

In this study, the influence of the presence of excipients in sample preparation and clean-up steps required prior to drug analysis in milk-based media which simulate the in vivo properties of the fed state stomach was investigated. 15 excipients, normally present in solid dosage forms of five APIs tested (atenolol, paracetamol, furosemide, nifedipine and propafenone hydrochloride) were mixed (one at a time) with the active pharmaceutical ingredient of interest either via vortexing, co-grinding or shaking of the physical mixture and dissolved in Fed State Simulated Gastric Fluid (FeSSGF). The objective of the study was the assessment of the extraction efficiency of three protein precipitation protocols (using MeOH, ΑCN and 10% w/v TCA), typically used in drug analysis, in milk-based biorelevant media in the presence of the excipients. The mixing technique, fat content of the medium and excipient and solvent effects were investigated. The efficiency of three different protein precipitation reagents in drug extraction when dissolved as API:excipient mixtures in the fed-state medium was compared against the equivalent drug amount recovered in the absence of the excipient in FeSSGF. Most excipients had a significant negative effect (p < 0.05) on drug recovery in the milk-based medium as indicated by the multiple linear regression (MLR) analysis performed. For magnesium stearate and HPMC, the % recovery values were the lowest in four out of the five drugs studied, with a range of 10-100% depending on the API, mixing technique and protein precipitation protocol selected. The negative excipient-dependent effect was more profound in nifedipine and propafenone hydrochloride, the most lipophilic compounds of the study. Acetonitrile was the most effective extraction reagent for most drugs in the presence of excipients, followed by methanol and 10% w/v trichloroacetic acid. Data analysis also revealed a dependence of the extraction method efficiency on the medium lipid content. Application of the above extraction protocols in commercially available formulations highlighted the need for assessment of the effect of excipients in extraction efficiency, before transferring the method directly to dissolution studies of formulations in milk-based fed gastric media. In conclusion, the presence of excipients and the selection of protein precipitation protocol are parameters which can affect significantly the efficiency of protein precipitation when FeSSGF is used as dissolution medium and need to be taken into consideration when developing a quantitative method based on the above sample clean-up technique.

Results and Patient Reported Outcome Measures (PROMs) after One-Stage Revision for Periprosthetic Joint Infection of the Hip: A Single-centre Retrospective Study.

Background: Little is known about functional outcome and quality of life (QoL) after one-stage revision for periprosthetic joint infection (PJI) of the hip. Methods: a cohort of 30 subjects treated with one-stage revision between 2011 and 2015 was identified, and questionnaires on functional outcome and QoL were distributed. Results: 28 subjects were successfully treated (93%). Most subjects were referred from other hospitals. Coagulase-negative Staphylococcus was found in 50% of the cases, and 40% of all cultured bacteria were multidrug-resistant. 25% had subsequent revision surgery, unrelated to PJI. Functional outcome was good and QoL scores were high, comparable to prosthetic joint revision surgery in general. Conclusion: Although the cohort was small and statistical analysis was not performed, this study showed that excellent results can be obtained with one-stage revision for hip PJI. Functional outcome and QoL was comparable to prosthetic joint revision surgery in general.

Strategic drug analysis in fed-state gastric biorelevant media based on drug physicochemical properties.

Milk-based media such as the Fed State Simulated Gastric Fluid (FeSSGF) are commonly used in order to simulate the in vivo properties of the fed state stomach. Due to the lack of a specific guideline for standardised sample clean-up in these media, the aim of the current study was to develop an optimum protocol for the extraction and quantification of drugs from the fed state gastric medium based on the APIs' physicochemical properties (lipophilicity, ionisation, aqueous solubility and protein binding). Two different extraction techniques, protein precipitation (PP) and solid phase extraction (SPE) were assessed. A pilot study in six model drugs was performed, with tests using seven different protein precipitation reagents at four different medium:reagent ratios and two drug concentrations as well as different solid phase extraction cartridges and elution protocols. % recovery was analysed using partial least squares (PLS) regression so as to determine the physicochemical parameters affecting the drug percentage recovered. For protein precipitation protocols, drug concentration, selection of protein precipitation reagent and ratio added to the medium significantly affected drug % recovery from FeSSGF (p < 0.05). The same applied for the selection of elution solvent and cartridge type for solid phase extraction. Optimum protocols using MeOH, ΑCN and 10% w/v TCA at a 1:2 FeSSGF:reagent ratio were effective to a larger group of drugs of a wide range of lipophilicity and ionisation, with ΑCN being the most effective in the whole range of log P values (-0.56 to 8.81). Solid phase extraction was proven to be effective for compounds of poor to moderate lipophilicity (log P < 4), with extremely hydrophobic compounds demonstrating lower % recovery values (down to 10% recovery). PLS demonstrated that only for 10% w/v TCA (protein precipitation) and HLB (solid phase extraction) can the effect of key drug physicochemical properties on the final amount of drug recovered be accurately predicted.

Pinnacle® modular metal-on-metal articulation in primary total hip arthroplasty: mid-term results of 195 cases.

Studies concerning Pinnacle® modular metal-on- metal (MoM) total hip arthroplasty (THA) show better results than for most other MoM THAs. The goal of this study was to report on the revision rate, clinical outcome and metal ion levels regarding this specific prosthesis. Retrospectively selected patients were evaluated clinically, and Visual Analogue Score for pain (VAS), Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) were determined. Blood metal ion levels were measured. 195 patients were included (mean follow-up 6.4 years). MoM related revision was performed in 5.1%. Clinical outcome was good, with a mean VAS of 6.7 out of 100, HHS of 88.9 and HOOS of 80.7. Five year survival was 96.6%, eight year survival decreased to 90.0%. No correlation could be found between metal ion levels and outcome. Although clinical outcome was good, overall survival of the Pinnacle® MoM is unacceptably low compared to MoP survival.

Quality of life after staged revision for infected total hip arthroplasty: a systematic review.

INTRODUCTION: The aim of this review was to assess (health-related) quality of life ([HR]Qol) after 1-stage or 2-stage revision for prosthetic joint infection of the hip (PJI). Additionally, we compared (HR)QoL scores with normative population scores to assess whether QoL is reduced after revision for PJI. METHODS: A systematic search was performed in Embase, Cochrane and Pubmed. We included articles that reported (HR)QoL questionnaires after staged revision for hip PJI with a minimum follow-up of 24 months. Methodological quality was assessed using the MINORS score. RESULTS: The search produced 11,195 results. We selected 12 papers describing 2-stage revisions. The mean MINORS score was 9.8. Average WOMAC scores of 185 patients with a mean follow-up of 69.8 months were 73.Average Short Form 36 (SF-36) scores of 159 patients with a mean follow-up of 40.7 months were 40.4 for the physical component score (PCS) and 51.6 for the mental component score (MCS). Average Short Form 12 (SF-12) scores of 154 patients with a mean follow-up of 73.4 months were: a PCS of 35.4 and a MCS of 49.1. The WOMAC, SF-12 (PCS) and SF-36 (PCS) were respectively 12%, 26.7% and 14.8% lower, compared to normative values. DISCUSSIONS: Patients who underwent 2-stage revision for hip PJI had substantially lower (physical component) (HR)QoL scores, but mental scores were comparable to the general population.

Fed-state gastric media and drug analysis techniques: Current status and points to consider.

Gastric fed state conditions can have a significant effect on drug dissolution and absorption. In vitro dissolution tests with simple aqueous media cannot usually predict drugs' in vivo response, as several factors such as the meal content, the gastric emptying and possible interactions between food and drug formulations can affect drug's pharmacokinetics. Good understanding of the effect of the in vivo fed gastric conditions on the drug is essential for the development of biorelevant dissolution media simulating the gastric environment after the administration of the standard high fat meal proposed by the FDA and the EMA in bioavailability/bioequivalence (BA/BE) studies. The analysis of drugs in fed state media can be quite challenging as most analytical protocols currently employed are time consuming and labour intensive. In this review, an overview of the in vivo gastric conditions and the biorelevant media used for their in vitro simulation are described. Furthermore an analysis of the physicochemical properties of the drugs and the formulations related to food effect is given. In terms of drug analysis, the protocols currently used for the fed state media sample treatment and analysis and the analytical challenges and needs emerging for more efficient and time saving techniques for a broad spectrum of compounds are being discussed.

Hair thread tourniquet syndrome in a toe of an 18 mo old girl.

Hair thread tourniquet syndrome is rare and usually affects little children. If the tourniquet is not incised, the affected body part becomes ischemic or even necrotic. An 18 mo old girl was seen in the emergency ward with a painful, red and swollen third toe of the left foot. The toe appeared to be strangulated with a hair, and the diagnosis hair thread tourniquet syndrome was made. After incision of the hair tourniquet the symptoms soon subsided. The diagnosis is easily made if the clinical features are recognized. However, if the tourniquet is not cut through, the affected body part may become ischemic and even necrotic.

Treatment of acute periprosthetic infections with prosthesis retention: Review of current concepts.

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, occurring in approximately 1%-2% of all cases. With growing populations and increasing age, PJI will have a growing effect on health care costs. Many risk factors have been identified that increase the risk of developing PJI, including obesity, immune system deficiencies, malignancy, previous surgery of the same joint and longer operating time. Acute PJI occurs either postoperatively (4 wk to 3 mo after initial arthroplasty, depending on the classification system), or via hematogenous spreading after a period in which the prosthesis had functioned properly. Diagnosis and the choice of treatment are the cornerstones to success. Although different definitions for PJI have been used in the past, most are more or less similar and include the presence of a sinus tract, blood infection values, synovial white blood cell count, signs of infection on histopathological analysis and one or more positive culture results. Debridement, antibiotics and implant retention (DAIR) is the primary treatment for acute PJI, and should be performed as soon as possible after the development of symptoms. Success rates differ, but most studies report success rates of around 60%-80%. Whether single or multiple debridement procedures are more successful remains unclear. The use of local antibiotics in addition to the administration of systemic antibiotic agents is also subject to debate, and its pro's and con's should be carefully considered. Systemic treatment, based on culture results, is of importance for all PJI treatments. Additionally, rifampin should be given in Staphylococcal PJIs, unless all foreign material is removed. The most important factors contributing to treatment failure are longer duration of symptoms, a longer time after initial arthroplasty, the need for more debridement procedures, the retention of exchangeable components, and PJI caused by Staphylococcus (aureus or coagulase negative). If DAIR treatment is unsuccessful, the following treatment option should be based on the patient health status and his or her expectations. For the best functional outcome, one- or two-stage revision should be performed after DAIR failure. In conclusion, DAIR is the obvious choice for treatment of acute PJI, with good success rates in selected patients.

One-stage revision in two cases of Salmonella prosthetic hip infection.

We describe two cases of prosthetic joint infection (PJI) of the hip due to Salmonella. The first patient presented with an early infection 5 d after being discharged following a total hip replacement and the second patient presented at the emergency ward with a late infection, thirteen years following a total hip replacement. Both cases occurred within one month of each other at our institution and both were successfully treated with a one-stage revision. PJI caused by Salmonella species is very rare: so far only 20 Salmonella PJIs of the hip have been described. Therefore, full consensus on the best treatment approach has not yet been reached. An aggressive two-stage approach is advised because of the virulence of Salmonella, although a limited number of successful one-stage approaches have been described as well. According to the latest guidelines, one-stage revision has comparable success rates and less morbidity compared to two-stage treatment, when selecting the right patients. In our opinion, PJI caused by Salmonella should be treated just as PJI caused by other bacteria, with consideration of the selection criteria as mentioned in several treatment guidelines. As illustrated by these two cases, one-stage revision can be successful in both early and late Salmonella PJI of the hip.

Comparison between open and arthroscopic procedures for lateral clavicle resection.

PURPOSE: Arthroscopic lateral clavicle resection (LCR) is increasingly used, compared to an open approach, but literature does not clearly indicate which approach is preferable. The goal of this study was to compare function and pain between patients who underwent lateral clavicle resection using an open approach and patients treated using an arthroscopic approach. METHODS: Patients who underwent LCR between January 2008 and December 2011 were reviewed. After exclusion, 149 shoulders (143 patients) were eligible for analysis: 41 open and 108 arthroscopic. Disabilities of arm, shoulder and hand (DASH) questionnaire and visual analogue scale (VAS) score were used to assess shoulder function and pain. Complications, operative time, length of hospitalization and resection distance were compared. RESULTS: At a mean follow-up of three years, patients in the open group had significantly less pain by VAS (mm) (Mdn 10, IQR 23) compared with arthroscopic patients (Mdn 20, IQR 50) (p = 0.036). Operative time (minutes) was significantly less for the open approach (Mdn 24.0, IQR 12) compared with arthroscopic (Mdn 38.0, IQR 15) (p < 0.001). Resection distance (mm) was larger for the open approach (Mdn 7.1, IQR 7.0) compared with the arthroscopic approach (Mdn 3.2, IQR 3.1) (p = 0.006), but was not associated with outcome. No significant differences were found for DASH score, complication rate or length of hospitalization. CONCLUSIONS: Both arthroscopic and open approaches for LCR provide excellent outcome in patients with acromioclavicular pain. Less residual pain was found for the open approach, which has shorter operating time and is likely more cost effective.

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections.

BACKGROUND AND PURPOSE: Fungal prosthetic joint infections are rare and difficult to treat. This systematic review was conducted to determine outcome and to give treatment recommendations. PATIENTS AND METHODS: After an extensive search of the literature, 164 patients treated for fungal hip or knee prosthetic joint infection (PJI) were reviewed. This included 8 patients from our own institutions. RESULTS: Most patients presented with pain (78%) and swelling (65%). In 68% of the patients, 1 or more risk factors for fungal PJI were found. In 51% of the patients, radiographs showed signs of loosening of the arthroplasty. Candida species were cultured from most patients (88%). In 21% of all patients, fungal culture results were first considered to be contamination. There was co-infection with bacteria in 33% of the patients. For outcome analysis, 119 patients had an adequate follow-up of at least 2 years. Staged revision was the treatment performed most often, with the highest success rate (85%). INTERPRETATION: Fungal PJI resembles chronic bacterial PJI. For diagnosis, multiple samples and prolonged culturing are essential. Fungal species should be considered to be pathogens. Co-infection with bacteria should be treated with additional antibacterial agents. We found no evidence that 1-stage revision, debridement, antibiotics, irrigation, and retention (DAIR) or antifungal therapy without surgical treatment adequately controls fungal PJI. Thus, staged revision should be the standard treatment for fungal PJI. After resection of the prosthesis, we recommend systemic antifungal treatment for at least 6 weeks-and until there are no clinical signs of infection and blood infection markers have normalized. Then reimplantation can be performed.

Prosthetic joint-associated infections treated with DAIR (debridement, antibiotics, irrigation, and retention): analysis of risk factors and local antibiotic carriers in 91 patients.

BACKGROUND AND PURPOSE: For prosthetic joint-associated infection (PJI), a regimen of debridement, antibiotics, irrigation, and retention of the prosthesis (DAIR) is generally accepted for acute infections. Various risk factors associated with treatment success have been described. The use of local antibiotic carriers (beads and sponges) is relatively unknown. We retrospectively analyzed risk factors in a cohort of patients from 3 hospitals, treated with DAIR for PJI. PATIENTS AND METHODS: 91 patients treated with DAIR for hip or knee PJI in 3 Dutch centers between 2004 and 2009 were retrospectively evaluated. The mean follow-up was 3 years. Treatment success was defined as absence of infection after 2 years, with retention of the prosthesis and without the use of suppressive antibiotics. RESULTS: 60 patients (66%) were free of infection at follow-up. Factors associated with treatment failure were: a history of rheumatoid arthritis, late infection (> 2 years after arthroplasty), ESR at presentation above 60 mm/h, and infection caused by coagulase-negative Staphylococcus. Symptom duration of less than 1 week was associated with treatment success. The use of gentamicin sponges was statistically significantly higher in the success group, and the use of beads was higher in the failure group in the univariate analysis, but these differences did not reach significance in the logistic regression analysis. Less surgical procedures were performed in the group treated with sponges than in the group treated with beads. INTERPRETATION: In the presence of rheumatoid arthritis, duration of symptoms of more than 1 week, ESR above 60 mm/h, late infection (> 2 years after arthroplasty), and coagulase-negative Staphylococcus PJI, the chances of successful DAIR treatment decrease, and other treatment methods should be considered.