The heavy burden and treatment challenges of fungal periprosthetic joint infection: a systematic review of 489 joints.

BACKGROUND: Fungal periprosthetic joint infection (FPJI) is an infrequent but devastating complication that imposes a heavy burden on patients. At present, a consensus regarding the most optimal surgical option for patients with FPJI, the ideal duration of systemic antifungal treatment, and many other issues has not been reached. METHODS: A comprehensive literature search was performed on the PubMed and Embase databases. The search criteria employed were as follows: (fungal OR candida OR mycotic) AND periprosthetic joint infection. Initially, the titles and abstracts were screened, and subsequently, studies deemed irrelevant or duplicative were eliminated. Following this, the complete texts of remaining articles were thoroughly examined. According to the inclusion and exclusion criteria, 489 joints in 24 articles were screened out. We further extracted the demographic characteristics (age, gender, body mass index, etc.), clinical presentation, fungal species, presence of bacterial coinfection, surgical methods, systemic and local antifungal therapy, and treatment outcomes. Subgroup data were analyzed according to fungal species and bacterial coinfection. Univariate logistic regression analysis was conducted to ascertain the risk factors associated with the infection recurrence. RESULTS: A total of 506 fungi were identified within 489 joints. The most prevalent fungal species were Candida albicans (41.5%). Out of 247 joints (50.5%) presenting with concurrent fungal and bacterial infections. Among the initial surgical interventions, two-stage exchange was the most common (59.1%). The infection recurrence rates of DAIR, resection arthroplasty, two-stage, one-stage, and three-stage exchange were 81.4%, 53.1%, 47.7%, 35.0%, and 30%, respectively. The mean duration of systemic antifungal therapy was 12.8 weeks. The most common drugs used both in intravenous (55.9%) and oral therapy (84.0%) were fluconazole. The proportion of patients who used antifungal drugs after replantation (two-stage and three-stage) was 87.6%. 33.2% of cement spacer or fixed cement contained antifungal drugs, of which amphotericin B was the main choice (82.7%). FPJI caused by candida albicans (OR = 1.717, p = 0.041) and DAIR (OR = 8.433, p = 0.003) were risk factors for infection recurrence. CONCLUSIONS: Two-stage exchange remains the most commonly used surgical approach. The reliability of one- and three-exchange needs further evaluation due to the small sample size. Antifungal-loaded cement spacers, and direct intra-articular injections of antimycotics after reimplatation should be strongly considered. Medication is not standardized but rather individualized according to microbiology and the status of patients.

Efficacy and Safety of Hyaluronic Acid Fillers With or Without Lidocaine in the Treatment of Nasolabial Folds: An Updated Systematic Review and Meta-Analysis.

OBJECTIVE: To update the evidence on the effectiveness and safety of hyaluronic acid gel combined with lidocaine for treating nasolabial folds. METHODS: We searched electronic databases including PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science using subject headings and keywords associated with hyaluronic acid and lidocaine in the context of nasolabial folds. Inclusion criteria were met by randomized controlled trials (RCTs) comparing the efficacy and safety of hyaluronic acid gel with or without lidocaine. Outcomes measured included visual pain analog scale (VAS) scores, wrinkle severity scale scores, and adverse events. The quality of RCTs was evaluated using the Cochrane Randomized Controlled Trials Scale, which encompasses criteria such as randomization, allocation concealment, blinding, dropout, and withdrawal rates, and was assessed by two independent reviewers. RESULTS: No significant difference in overall wrinkle severity rating scale scores was observed between HA with lidocaine and HA without lidocaine [MD = 0.08, 95% CI (- 0.09, 0.24), P = 0.36]. However, there was a significant reduction in pain scale scores (VAS) [SMD = -2.47, 95% CI (- 4.15, - 0.79), P = 0.004]; no significant differences were noted in the ncidence of at least one adverse event [RR = 0.97, 95% CI (0.90, 1.05), P = 0.51]; and there were no significant differences in swelling [RR =  0.99, 95% CI (0.92, 1.06), P = 0.80], erythema [RR = 1.01, 95% CI (0.91, 1.11), P = 0.91], bruising [RR = 0.99, 95% CI (0.89, 1.13), P = 0.86], itching [RR = 1.03, the 95% CI (0.88, 1.21), P = 0.74], induration [RR = 1.04, 95% CI (0.92, 1.17), P = 0.55], and papules [RR = 0.77, 95% CI (0.58, 1.02), P = 0.07]. There was a significantly lower incidence of tenderness [RR = 0.91, 95% CI (0.86, 0.97), P = 0.002] only in the control group. Sensitivity analysis confirmed the stability of results across all outcome indicators with low sensitivity and high confidence. Subgroup analysis indicated higher wrinkle severity scores among East Asians compared to Europeans and Americans. CONCLUSIONS: HA containing lidocaine significantly reduces pain and is comparable in effectiveness and safety of HA without lidocaine. The clinical effects appear more pronounced in East Asians. Due to the limited number of related studies, further research is necessary. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vancomycin presoak reduces infection in anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

PURPOSE: To compare the effect of vancomycin presoak treatment of grafts during anterior cruciate ligament reconstruction on the incidence of postoperative infection or septic arthritis. METHODS: Studies published before May 3, 2022 investigating vancomycin presoak of grafts during anterior cruciate ligament reconstruction were searched in the PubMed and Cochrane Central Register of Controlled Trials. Studies were screened, and data on the incidence of postoperative infection or septic arthritis were extracted and included in the analysis. RESULTS: Thirteen studies were included for analysis after search screening, yielding a total of 31,150 participants for analysis, of whom 11,437 received graft vancomycin presoak treatment, and 19,713 did not receive treatment. Participants who received vancomycin treatment had significantly lower infection rates (0.09% versus 0.74%; OR 0.17; 95% CI 0.10, 0.30; P < 0.00001). CONCLUSION: Pre-soaking of the graft with vancomycin during ACL reconstruction reduced the incidence of postoperative infection and septic arthritis.

Use of a new off-the-shelf 3D-printed trabecular titanium acetabular cup in Chinese patients undergoing hip revision surgery: Short- to mid-term clinical and radiological outcomes.

BACKGROUND: Revision total hip arthroplasty (THA) has been a challenge for surgeons. The purpose of this study was to explore the short-to mid-term clinical and radiological outcomes of Chinese patients who underwent revision THA using a new off-the-shelf three-dimensional (3D)-printed trabecular titanium (TT) acetabular cup by comparison with a conventional porous coated titanium acetabular cup, to provide a reference for the recommendation of this prostheses. METHODS: A retrospective analysis of 57 patients (57 hips) who received revision THA was performed from January 2016 to June 2019. A total of 23 patients received 3D-printed cups (observation group) and 34 patients received non-3D-printed cups (control group). Clinical scores including Visual Analogue Scale (VAS), Harris Hip Score (HHS) and Short Form 36 (SF-36), upward movement of the hip center of rotation(HCOR)and limb-length discrepancy (LLD), stabilization and bone ingrowth of cups were compared between two groups. The multivariate linear regression was used to determine the factors potentially influencing the HHS score. Postoperative complications in the two groups were also recorded. RESULTS: All 57 patients were routinely followed up. The average follow-up durations in the control and observation groups were 43.57 ± 13.68 (24-65) months and 41.82 ± 11.44 (24-64) months, respectively (p = 0.618). The postoperative clinical scores significantly improved in both groups compared to the preoperative scores (p < 0.001). The VAS score did not significantly differ between the groups at 3 (p = 0.946) or 12 (p = 0.681) months postoperatively, or at the last follow-up (p = 0.885). The HHS score did not significantly differ between the groups at 3 months (p = 0.378) postoperatively but differed at 12 months (p < 0.001) postoperatively and the last follow-up (p < 0.001). The SF-36 score did not significantly differ between the groups at 3 months (p = 0.289) postoperatively, but was significantly different at 12 months (p < 0.001) postoperatively and the last follow-up (p < 0.001). Compared with the control group, the postoperative recovery of HCOR and LLD was better in the observation group. All cups remained stable, with no loosening throughout the follow-up period. But the observation group had a significantly better rate of bone ingrowth compared to the control group (p = 0.037). Multivariate linear regression analysis showed that different cup types, upward movement of the HCOR, and LLD influenced the HHS score at the last follow-up (p < 0.001, p = 0.005, respectively). None of the patients exhibited severe postoperative complications. CONCLUSION: The new off-the-shelf 3D-printed TT acetabular cup demonstrated encouraging short-to mid-term clinical outcomes in Chinese patients. It can effectively relieve pain, improve hip function, provide satisfactory biological fixation and high survival rate. But further follow up is necessary to assess its long-term outcomes.

Zoledronic acid and teriparatide have a complementary therapeutic effect on aseptic loosening in a rabbit model.

BACKGROUND: Revisions are mainly caused by wear debris-induced aseptic loosening. How to effectively suppress debris-induced periprosthetic osteolysis has become an urgent problem. Both zoledronic acid and teriparatide can increase the bone mass around prostheses and increase the stability of prostheses. A hypothesis was proposed: the combination of the two drugs may have a better treatment effect than the use of either drug alone. METHODS: We created a rabbit model to study the effect and mechanism of the combination of zoledronic acid and teriparatide in the treatment of aseptic loosening. Thirty-two adult male New Zealand white rabbits were selected and treated with TKA surgery, and a titanium rod prosthesis coated evenly with micrometre-sized titanium debris was implanted into the right femoral medullary cavity. All rabbits were randomized into four groups (control group = 8, zoledronic acid group = 8, teriparatide group = 8, and zoledronic acid + teriparatide group = 8). All the animals were sacrificed in the 12th week, and X-ray analyses, H&E staining, Goldner-Masson trichrome staining, von Kossa staining, and RT-PCR and Western blotting of the mRNA and protein of OCN, OPG, RANKL and TRAP5b in the interface membrane tissues around the prostheses were immediately carried out. RESULTS: The results shown that both zoledronic acid and teriparatide could inhibit debris-induced peri-prosthetic osteolysis and promote new bone formation. Zoledronic acid was more capable of inhibiting osteoclast activation and peri-prosthetic osteolysis, while teriparatide was more capable of promoting osteoblast function and peri-prosthetic bone integration. CONCLUSION: This research confirmed that the combination of zoledronic acid and teriparatide could prevent and treat aseptic loosening of the prosthesis more effectively. However, the safety of this combination and the feasibility of long-term application have not been ensured, and the clinical application requires further experiments and clinical research support.

A prospective comparative study of staged total knee arthroplasty: ninety-day versus seven-day interval.

PURPOSE: The optimal interval between staged bilateral total knee arthroplasty (STBTKA) is unclear. Studies have reported STBTKA being performed at the same admission, with a seven day interval. The safety and outcomes of patients submitted to same-admission STBTKA (SA-STBTKA) are questionable and need further investigation. METHODS: A prospective non-randomized study was performed to compare the early postoperative outcomes, systemic complications, and surgical-related complications between the first and second knees, as well as between SA-STBTKA and STBTKA groups. From July 2018 to November 2019, a total of 430 patients were recruited. Analyzed parameters included the Knee Society score (KSS), Knee Society functional score (KSFS), range of motion (ROM), Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain score, WOMAC stiffness score, and WOMAC score for daily life difficulty. RESULTS: Pre-operatively, the demographic data and functional scores were not significantly different between the two groups. The KSS, WOMAC pain score, and WOMAC stiffness score of the second knee in the STBTKA group were significantly better than those of the first knee. A total of 426 patients completed the last follow-up one  year after surgery, and the post-operative functional scores were not significantly different between the two groups and between the two knees within the same group. Before the second operation, more systemic complications were identified in the SA-STBTKA group, while the rate of surgical complication was not significantly different when compared to STBTKA patients. CONCLUSIONS: With equivalent post-operative function and a higher frequency of minor complications, SA-STBTKA should be cautiously selected as a treatment option for bilateral osteoarthritis.

Globulin and albumin to globulin ratio precisely diagnose periprosthetic joint infection and determine the timing of second-stage reimplantation.

BACKGROUND: Periprosthetic joint infection (PJI) is one of the most challenging complications of total joint arthroplasty (TJI). An early and accurate diagnosis of PJI is associated with better treatment outcomes. However, whether the platelet-related markers and globulin-related markers can be used to assist the diagnosis of PJI remains elusive. METHODS: A total of 206 patients who underwent revision hip or knee arthroplasty in our institution were divided into two groups: 79 patients in PJI group and 127 patients in aseptic failure group. The levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelet-related markers including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT) and PLT to MPV ratio (PMR) and globulin-related markers such as globulin (GLB), albumin to globulin ratio (AGR) and PLT to AGR ratio were compared. The diagnostic value was measured using area under the curve (AUC) after constructing receiver operating characteristic (ROC) curves. The potential of each marker for determining the timing of second-staged reimplantation was also evaluated. RESULTS: Significantly increased levels of ESR, CRP, PLT, PCT, PMR, GLB and PLT to AGR ratio were identified in PJI group, while decreased levels of MPV and AGR were also found. The diagnostic values of all platelet-related markers and GLB were considered as fair, and good diagnostic values of AGR and PLT to AGR ratio were found, which were comparable to those of ESR and CRP. The levels of GLB and AGR can also be used to predict negative culture result and the timing of second-stage reimplantation. CONCLUSIONS: Globulin and albumin to globulin ratio were found to have good diagnostic values for PJI, and they can precisely predict the culture results and persistent infection.

Using short knee radiographs to predict the coronal alignment after TKA: Is it an accurate proxy for HKA on full-length images?

BACKGROUND: The postoperative clinical outcomes has been extensively demonstrated to correlate with the coronal alignment after total knee arthroplasty (TKA). However, in different studies, either the hip-knee-ankle angle (HKA) on a full-length radiograph or the femorotibial angle (FTA) on a short knee film was used to categorize the postoperative coronal alignment. Meanwhile, several different FTA ranges were regarded as neutral alignment in different studies. As a result, it is still unknown that how FTA on short knee films and HKA related to each other. The FTA may be able to become an accurate proxy of HKA to predict the coronal alignment. The purpose of this study was to explore the correlation between the FTA and the HKA after TKA and to find the most accurate FTA range. METHODS: About 223 patients were included in this study and standard weight-bearing short knee films as well as full-length radiographs were acquired. The pre- and postoperative FTA, as well as the postoperative anatomical lateral distal femoral angle (aLDFA) and anatomical medial proximal tibial angle (aMPTA) were measured on short knee films by two orthopedic surgeons independently. On full-length films, the pre- and postoperative FTA, the pre- and postoperative HKA, as well as the postoperative mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibial angle (mMPTA) were also recorded by two other surgeons independently. Pearson correlation analysis was performed to compare FTA and HKA, aMTPA and mMTPA, aLDFA and mLDFA, respectively. RESULTS: The postoperative FTA and HKA had a good correlation (r = 0.86). The agreements were reached 82.7%, 71.0%, and 68.2% of all patients using three previously reported FTA ranges. When analyzing the independent alignment of the tibial tray and the femoral component, 84.1% and 57.9% of all patients was reached an agreement on the classification. CONCLUSIONS: On most occasions, the consistence between the FTA and HKA in assessing the coronal limb alignment of the lower extremity and the tibial component is satisfactory. However, the postoperative full-length film is still needed to evaluate accurately the coronal alignment of the femoral component.

Plasma fibrinogen is a reliable marker for diagnosing periprosthetic joint infection and determining the timing of second-stage revision.

OBJECTIVES: We investigated the diagnostic value of fibrinolytic markers for periprosthetic joint infection (PJI), determined their relationship with culture results, and evaluated whether these markers could assess infection control and determine the timing of second-stage reimplantation. DESIGN/METHODS: This single-center-retrospective study included 206 patients who underwent revision hip or knee arthroplasty (PJI group, n = 79; aseptic loosening [AL] group, n = 127). The plasma levels of fibrinogen, d-dimer, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were compared, and receiver operating characteristic curves were constructed. Subgroup analysis within the PJI group was also performed. RESULTS: The plasma levels of fibrinogen, d-dimer, ESR, and CRP were significantly lower in the AL group, with an area under the curve of 0.848, 0.669, 0.865, and 0.841, respectively. The plasma level of d-dimer was significantly lower in patients with culture-negative PJI. In patients with residual infection, the levels of all the markers had not significantly changed, while noticeably decreased plasma levels of fibrinogen, ESR, and CRP were detected in patients with successful second-stage reimplantation. CONCLUSIONS: Plasma fibrinogen is a promising marker for diagnosing PJI and evaluating persistent infection. Decreased plasma levels of d-dimer in patients with PJI might be linked with negative culture results.