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.

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.

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Background and purpose: In the last decade, the direct anterior approach (DAA) for total hip arthroplasty (THA) has become more popular in the Netherlands. Therefore, we investigated the learning curve and survival rate of the DAA in primary THA, using data from the Dutch Arthroplasty Register (LROI).Patients and methods: We identified all patients who received a primary THA using the DAA in several high-volume centers in the Netherlands between 2007 and 2019 (n = 15,903). Procedures were ordered per surgeon, using date of operation. Using the procedure number, operations were divided into 6 groups based on the number of previous procedures per surgeon (first 25, 26–50, 51–100, 101–150, 151–200, > 200). Data from different surgeons in different hospitals was pooled together. Revision rates were calculated using a multilevel time-to-event analysis.Results: Patients operated on in group 1–25 (hazard ratio [HR] 1.6; 95% CI 1.1–2.4) and 26–50 (HR 1.6; CI 1.1–2.5) had a higher risk for revision compared with patients operated on in group > 200 THAs. Between 50 and 100 procedures the revision risk was increased (HR 1.3; CI 0.9–1.9), albeit not statistically significant. From 100 procedures onwards the HR for revision was respectively 1.0 (CI 0.6–1.6) and 0.8 (CI 0.5–1.4) for patients in operation groups 101–150 and 151–200. Main reasons for revision were loosening of the stem (29%), periprosthetic infection (19%), and dislocation (16%).Interpretation: We found a 64% increased risk of revision for patients undergoing THA using the DAA for the first 50 cases per surgeon. Between 50 and 100 cases, this risk was 30% increased, but not statistically significant. From 100 cases onwards, a steady state had been reached in revision rate. The learning curve for DAA therefore is around 100 cases.

Background: Different surgical approaches for total hip arthroplasty (THA) exist, without predisposition when it comes to dislocation risk. The direct anterior approach (DAA) is thought to have reduced risk since soft tissue trauma is minimalized. Therefore, we assessed the dislocation risk for different surgical approaches, and the relative dislocation risk of DAA compared to other approaches. Methods: Six electronic databases were systematically searched for prospective studies reporting dislocation following THA. Proportion meta-analyses were performed to assess the dislocation rate for subgroups of the surgical approach. Meta-analysis for binary outcomes was performed to determine the relative risk of dislocation for the DAA compared to other approaches. Results: Eleven studies with 2025 patients were included (mean age 64.6 years, 44% male, mean follow-up 10.5 months), of which four studies were also used in the risk ratio meta-analysis. Overall dislocation rate was 0.79% (95% CI 0.37–1.69). Subgroup analyses showed that most dislocations occurred in the posterior approaches group (1.38%), however non-significant. Furthermore, the DAA emerged with a non-significant lower risk of dislocation (RR 0.37, 95% CI 0.05–2.46) compared to other surgical approaches. Conclusion: Current literature shows non-significant predisposition for a surgical approach to THA regarding dislocation risk. To what extent patient characteristics influence the risk of dislocation could not be determined. Future research should focus on this, as well as on the influence of a surgeon's experience with a specific approach.