What’s New in Musculoskeletal Infection

Abstract

Periprosthetic joint infection (PJI) remains the most dreaded complication after total joint arthroplasty (TJA). As reimbursement for joint replacement continues to decline [1][2][3] , fewer orthopaedic surgeons take on this challenging and timeconsuming practice. Indeed, in a recent study, Keely Boyle et al. found that 16% of knee arthroplasty revisions, including revisions for infection, were performed at a different center than the one in which the index procedure was performed. Illgen et al. used the American Joint Replacement Registry (AJRR) to show that, in hips, the migration rate for PJI ranges from 28.6% to 46.6%, depending on the size of the hospital 5 . This places a major portion of the responsibility of PJI care on a few specialized surgeons. Therefore, understanding the economics of PJI care has been a hot topic this year.In a study utilizing the National Inpatient Sample (NIS), Premkumar et al. projected that, by 2030, the annual hospital costs related to PJI of the hip and knee will equal $1.85 billion in the United States 6 . In another study from a single institution, the cost of care for a PJI after a 2-stage total knee arthroplasty (TKA) was more than 5 times the cost of care of an uncomplicated primary TKA for an age-matched and body mass index (BMI)-matched cohor t 7 . Comparing the cost of operative treatment for PJI of the hip and knee with that of aseptic revision, Yao et al. 8 showed that the PJI treatment had costs that were double those of the aseptic treatment. Unintended hospitalization during the 2-stage exchange process was shown to add >$20,000 in costs to patient care, which is concerning because less than one-half of the patients who underwent resection for PJI had a successful 2-stage exchange within 1 year 9 . Using a Markov model, Antonios et al. showed the costeffectiveness of adding a planned second debridement, antibiotics, and implant retention (DAIR) procedure to treat PJI 10 . Efforts to reduce failure in PJI treatment will continue to be an important topic in research. PreventionAlthough originally spoken to Philadelphians to increase fire awareness in the 1700s, Benjamin Franklin's famous quote, "An ounce of prevention is worth a pound of cure," certainly still applies to PJI. With the substantial clinical and financial burden of PJI, resources should be focused, not just on treatment, but on optimizing strategies to prevent infection. Many studies published on this topic at this time will help to guide orthopaedic surgeons and their perioperative management of patients undergoing total hip arthroplasty (THA) and TKA, while prompting more prospective studies to answer important questions.Preoperative Staphylococcus aureus screening is controversial. In a recent systematic review and meta-analysis with 32 studies, Ribau et al. identified a marked reduction in infection with decolonization prior to elective THA and TKA 11 . However, in a randomized controlled trial (RCT) of 613 patients, Rohrer et al. did not find a difference in PJI rates with nasal decolonization, but...