Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate.

BACKGROUND: Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients. METHODS: A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance. RESULTS: The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis. CONCLUSIONS: Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Contemporary Dual Mobility Head Penetration at Five Years: Concern for the Additional Convex Bearing Surface?

BACKGROUND: Dual mobility (DM) bearings are increasingly popular and second-generation designs contain highly cross-linked polyethylene. The purpose of this study is to report head penetration rates in modern DM bearings. METHODS: A review of 63 consecutive DM bearings was performed. Radiographs were analyzed for head penetration using Martell methodology at regular postoperative intervals. RESULTS: Thirty-four DM bearings were analyzed. Mean linear head penetration was 1.59 mm/y at 1 year, 1.07 mm/y at 2 years, and 0.27 mm/y at 5 years following an exponential regression model (R2 = 0.999). Mean volumetric wear was 783 mm3/y at 1 year, 555 mm3/y at 2 years, and 104 mm3/y at 5 years following an exponential regression model (R2 = 0.986). CONCLUSION: Initial head penetration of DM bearings is larger than contemporary cross-linked polyethylene bearings; however, rates approach steady state after 2 years, analogous to traditional bearings. The larger "bedding-in" head penetration may be due to the additional convex bearing surface, creating 2 surfaces for deformation/wear.

Mid-term Results of Femoral and Tibial Osteotomies and Fassier-Duval Nailing in Children With Osteogenesis Imperfecta.

BACKGROUND: Patients with osteogenesis imperfecta (OI) have significant burden of both fractures and bony deformities. The present approach to care in this disorder is a combination of surgical care with intramedullary rod fixation, cyclic bisphosphonate therapy, and rehabilitation with goal of maximizing patient function and quality of life. METHODS: Retrospective chart review identified 58 children with OI who had realignment osteotomies with Fassier-Duval (FD) intramedullary nailing of the lower extremity by a single surgeon. This is a consecutive series treated between 2003 and 2010. Postoperatively, patients were followed up clinically and radiologically. Motor function was assessed using the Brief Assessment of Motor Function score and the walking scale subset of the Gillette Functional Assessment Questionnaire. RESULTS: Fifty-eight patients had 179 lower extremity FD intramedullary rods placed. This technique allowed for intervention on multiple long bones, with 29% having bilateral femur and tibial rodding in the same procedure. Revisions were required in 53% of patients, which occurred at a mean time of 52 months after initial rodding surgery. In most cases, revision surgery was related to patient growth and subsequent fracture, although rod migration did occur in a minority of patients. Nonunion or incomplete union was 14.5% in this series. Bisphosphonate infusion was not postponed after surgical procedures. Patients had improvement in mobility status at the latest follow-up. CONCLUSIONS: This series lends evidence to the medium-term utility of FD intramedullary rods as an effective and less invasive platform for stabilization and correction of deformity in long bones of patients with OI. Relatively low blood loss and relatively short hospitalizations were noted. Nonunion rate was comparable with existing literature noting that our patients did not have postsurgical postponement of bisphosphonate therapy. LEVEL OF EVIDENCE: Therapeutic study to investigate the results of treatment with FD rods. Retrospective case series model of Level IV evidence quality.

Periprosthetic joint infection: the economic impact of methicillin-resistant infections.

The orthopedic community has begun to witness a worrisome rise in the incidence of periprosthetic joint infections (PJIs) caused by resistant organisms. Besides other challenges associated with treating these infections, it appears that these infections may pose a higher cost compared to infections caused by sensitive organisms. Significantly higher cost of care for treatment of infections due to methicillin-resistant organisms were seen at a mean of $107,264 per case compared to $68,053 for treating PJI caused by sensitive strains (P < .0001). More effective strategies for preventing the spread of infections caused by resistant organisms need to be implemented to ease the social and economic strains facing the orthopedic community due to resistant organisms.

Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited.

Irrigation and debridement (I and D) is a procedure commonly used for the treatment of acute periprosthetic infection. This study retrospectively reviewed clinical records of patients with periprosthetic infection of the hip or knee who underwent I and D with retention of their prostheses between 1997 and 2005 at a single institution. One hundred four patients (44 males and 60 females) were identified. Mean age at time of initial debridement was 65 years. Average follow-up was 5.7 years. Treatment failure was defined as the need for resection arthroplasty or recurrent microbiologically proven infection. According to these criteria, I and D was successful in 46 patients (44%). Patients with staphylococcal infection, elevated American Society of Anesthesiologists score, and purulence around the prosthesis were more likely to fail. The high failure rate of this procedure implies that it should be preferably limited to select healthy patients with low virulence organisms and equivocal intraoperative findings.

Early failure of a nonmodular titanium femoral stem after primary hip arthroplasty.

Fully porous-coated cementless implants have a low failure rate and excellent survivorship in primary and revision surgery. Failure secondary to implant fracture is extremely rare with modern implant designs. We report an early fracture of a fully porous-coated femoral stem after primary total hip arthroplasty. The implant failed because of a filling mismatch between the proximal and distal femur.