Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.
We report a case of bilateral displaced acetabular fractures including both columns fractures with protrusio acetabuli in a female patient, aged 15 years, with osteogenesis imperfecta (OI) (Sillence Type I), epilepsy, blue sclera and bilateral ipoacusia. Since OI is a rare genetic disorder characterized by an increased propensity to osteopenia, intraoperative fracture risks and hemorrhagic diathesis, we opted for the open reduction and internal fixation of the acetabula in two surgical steps and using two different approaches. Although the clinical outcomes are not excellent in this report (HHS 45/100), the authors suggest that chances of a good outcome with reconstruction of the acetabulum must be balanced against the benefits of early or late total hip arthroplasty. The goal was to delay a joint replacement as long as possible due to the patient's young age.Level of evidence: V, case report.
PurposeModern total knee arthroplasty (TKA) systems are designed to reproduce the normal knee kinematics and improve patient outcome. The authors compared two different third‐generation medial pivot TKA implants, having a single‐radius or a J‐curve design in their sagittal plane, hypothesizing no clinical differences. MethodsTwo cohorts of 50 patients who underwent primary TKA were first preoperatively matched by sex, deformity, body mass index (BMI), Oxford Knee Score (OKS), Knee society score (KSS) and range of motion (ROM) and then statistically analyzed at a minimum follow‐up (FU) of 2 years. An identical surgical technique, which aimed to reproduce a slightly tighter medial than lateral compartment, was used in all knees. ResultsAt a minimum follow‐up of 2 years (range 24–34 months) there were no statistically significant differences in OKS and KSS between the two implant groups. The final ROM differed statistically between the two groups: the average maximum active flexion was 123° in the J‐curve femoral design group with an adapted “medially‐congruent” polyethylene insert, and 116° in the single radius femoral design with a medial “ball‐in‐socket” articulation. ConclusionNo clinical and radiological differences were found when the two cohorts of patients were compared. This study showed that the implant design played a minor role in the final outcome as opposed to a precise surgical technique. Level of evidenceRetrospective case‐control study, Level III.
In this article the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure to improve the possibilities of retaining a total hip arthroplasty (THA) undergoing acute periprosthetic joint infection (PJI). This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads. The combination of 3 different surgical techniques (tumour-like synovectomy, Argon Beam application and chlorhexidine gluconate brushing) might enhance the disruption and removal of the bacterial biofilm which is the main responsible of antibiotics and antibodies resistance. The timing of the diagnosis (6 weeks from the original surgery or 1 week from clinical symptoms appearance in the case of an hematogenous infection) and the preoperative isolation of the germ are fundamental in order to obtain a satisfactory outcome. A 12-week course of postoperative antibiotic therapy (6 weeks I.V. and 6 weeks oral) complete the postoperative protocol used by the authors. The DAPRI technique might represent a safe and more conservative treatment for acute and early hematogenous PJI.
Purpose Synovial fluid cultures of periprosthetic joint infections (PJI) may be limited by bacteria living in the fluids as biofilm-aggregates. The antibiofilm pre-treatment of synovial fluids with dithiotreitol (DTT) could improve bacterial counts and microbiological early stage diagnosis in patients with suspected PJI. Methods Synovial fluids collected from 57 subjects, affected by painful total hip or knee replacement, were divided into two aliquots, one pre-treated with DTT and one with normal saline. All samples were plated for microbial counts. Sensitivity of cultural examination and bacterial counts of pre-treated and control samples were then calculated and statistically compared. Results Dithiothreitol pre-treatment led to a higher number of positive samples, compared to controls (27 vs 19), leading to a statistically significant increase in the sensitivity of the microbiological count examination from 54.3 to 77.1% and in colony-forming units count from 1884 ± 2.129 CFU/mL with saline pre-treatment to 20.442 ± 19.270 with DTT pre-treatment (P = 0.02). Conclusions To our knowledge, this is the first report showing the ability of a chemical antibiofilm pre-treatment to increase the sensitivity of microbiological examination in the synovial fluid of patients with peri-prosthetic joint infection. If confirmed by larger studies, this finding may have a significant impact on routine microbiological procedures applied to synovial fluids and brings further support to the key role of bacteria living in biofilm-formed aggregates in joint infections.
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