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Background Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary.Questions/purposes (1) At second-stage reimplantation surgery, what is the diagnostic accuracy of frozen sections as compared with the Musculoskeletal Infection Society (MSIS) as the gold standard? (2) What are the diagnostic accuracy parameters for the MSIS criteria and frozen sections in predicting failure of reimplantation? (3) Do positive MSIS criteria or frozen section at the time of reimplantation increase the risk of subsequent failure? Methods A total of 97 patients undergoing the second stage of revision total hip arthroplasty or total knee arthroplasty in 2013 for a diagnosis of periprosthetic joint infection (PJI) were considered eligible for the study. Of these, 11 had incomplete MSIS criteria and seven lacked 1-year followup, leaving 79 patients (38 knees and 41 hips) available for analysis. At the time of reimplantation, frozen section results were compared with modified MSIS criteria as the gold standard in detecting infection. Subsequently, success or failure of reimplantation was defined by (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality; and diagnostic parameters in predicting treatment failure were calculated for both the modified MSIS criteria and frozen sections.One author (WB) has received research support in the amount of USD 100,001 to USD 1,000,000 from grants from Stryker (Kalamazoo, Conclusions On the basis of our results, both frozen section and MSIS are recommended at the time of the second stage of revision arthroplasty. Both frozen section and modified MSIS criteria had limited screening capabilities to identify failure, although both demonstrated high specificity. MSIS criteria should be evaluated at the second stage of revision arthroplasty because performing reimplantation in a joint that is positive for infection significantly increases the risk for subsequent failure. Level of Evidence Level III, diagnostic study.MI123 Clin Orthop Relat Res (2016) 474:1619-1626 DOI 10.1007/s11999-015-4673-3 Clinical Orthopaedics and Related Research ® A Publication of The Association of Bone and Joint Surgeons® Results At the time of second-stage reimplantation sur

Total femoral replacement (TFR) is a salvage arthroplasty procedure used as an alternative to lower limb amputation. Since its initial description in the mid-20(th) century, this procedure has been used in a variety of oncologic and non-oncologic indications. The most compelling advantage of TFR is the achievement of immediate fixation which permits early mobilization. It is anticipated that TFR will be increasingly performed as the rate of revision arthroplasty rises worldwide. The existing literature is mainly composed of a rather heterogeneous mix of retrospective case series and a wide assortment of case reports. Numerous TFR prostheses are currently available and the surgeon must understand the unique implications of each implant design. Long-term functional outcomes are dependent on adherence to proper technique and an appropriate physical therapy program for postoperative rehabilitation. Revision TFR is mainly performed for periprosthetic infection and the severe femoral bone loss associated with aseptic revisions. Depending on the likelihood of attaining infection clearance, it may sometimes be advisable to proceed directly to hip disarticulation without attempting salvage of the TFR. Other reported complications of TFR include hip joint instability, limb length discrepancy, device failure, component loosening, patellar maltracking and delayed wound healing. Further research is needed to better characterize the long-term functional outcomes and complications associated with this complex procedure.

Level II.

Background Studies have suggested that the success of two-stage revision total knee arthroplasty (rTKA) may be compromised by a prior failed irrigation and debridement (I&D). The purpose of this study was to use two large state inpatient databases to compare the two-stage rTKA failure rates for those patients with and without a prior I&D. Methods This retrospective, longitudinal study used inpatient discharge data from the State Inpatient Database (SID) of two states (California and New York) from 2005 to 2011. A combination of ICD-9 diagnosis and procedure codes were used to identify rTKA patients, and compare failure rates for rTKA patients with and without prior I&D. The primary outcome was failure of the staged revision, which was defined as subsequent surgery due to infection within four years of the two-stage rTKA. Results Of the 750 patients who underwent two-stage rTKA, fifty-seven had undergone a prior I&D. In all, 126 patients failed rTKA. After four years, the estimated failure rate was 8.7% (95% CI 1.9% – 16.9%) in the group with prior I&D and 17.5% (95% CI 14.7% – 20.4%) in the group without prior I&D. After adjusting for gender, race, insurance, median household income, and comorbidities, the hazard ratio for the group with a failed I&D was 0.49 (p=0.122; 95% CI 0.20 – 1.20) which indicated a lower risk of failure compared to the group without prior I&D. Conclusions These findings indicate that the failure rate of two-stage rTKA is not increased by prior failed I&D.

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Implant documentation in total knee arthroplasty (TKA) must be both accurate and comprehensive. A new system enables surgeons to complete a secure, web-based operative report for each surgery. This study evaluated implant documentation using this system and hypothesized that it would be as reliable as the current standard. This was a retrospective study of all primary and revision TKA performed at a single academic institution from January 1, 2015 to March 31, 2015, by eight adult reconstruction surgeons who used the web-based system. Electronic medical records and implant logbooks were chosen as a composite standard reference for implant documentation. Cohen's kappa statistic and Pearson's correlation coefficients were used to determine agreement between the system and the standard reference. Mean kappa value for entire system was 0.916 ± 0.152 ( = 0.015) indicating "almost perfect" agreement (as per Landis and Koch's method) with standard reference. Pearson's correlation coefficient was 0.926 ± 0.147 ( = 0.021) further corroborating this excellent agreement. There was "substantial" or "fair" agreement for items pertaining to cement and augments. Overall, sensitivity was 0.98 (95% confidence interval: 0.71-0.98) and specificity 0.93 (95% confidence interval: 0.53-0.98) indicating that the system was very effective at documenting whether or not an implant was placed. The system exhibited significantly greater sensitivity than specificity ( = 0.027). This study demonstrated excellent performance of this novel system in point-of-care TKA implant documentation. Further research is needed to validate its use in arthroplasty of other joints and its potential for documentation of biomedical device implantation in other fields such as cardiothoracic surgery and gastroenterology.

Protocols for the screening and decolonization of Staphylococcus aureus prior to total joint arthroplasty (TJA) have become widely adopted. The goals of this study were to determine: (1) whether implementation of a screening protocol followed by decolonization with mupirocin/vancomycin and chlorhexidine reduces the risk of revision compared with no screening protocol (i.e., chlorhexidine alone) and (2) whether clinical criteria could reliably predict colonization with MSSA and/or MRSA. Electronic medical records of primary patients undergoing TJA that were screened (n = 3,927) and were not screened (n = 1,751) for Staphylococcus aureus at least 4 days prior to surgery, respectively, were retrospectively reviewed. All patients received chlorhexidine body wipes preoperatively. Patients carrying MSSA and MRSA were treated preoperatively with mupirocin and vancomycin, respectively, along with the standard preoperative antibiotics and chlorhexidine body wipes. Screened patients were 50% less likely to require revision due to prosthetic joint infection compared to those not screened (p = 0.04). Multivariate regression models were poorly accurate in predicting colonization with MSSA (AUC = 0.58) and MRSA (AUC = 0.62). These results support the routine screening and decolonization of S. aureus prior to TJA.