• 2 stage revision
• EBJIS
• MSIS
• arthroplasty
• diagnosis
• periprosthetic joint infections
• revision
• total hip replacement
• total knee replacement

• PJI
• arthroplasty
• hip
• infection
• revision

• Humans
• Arthroplasty, Replacement, Hip/methods
• Follow-Up Studies
• Prosthesis-Related Infections/epidemiology
• Prosthesis-Related Infections/etiology
• Prosthesis-Related Infections/surgery
• Retrospective Studies
• Treatment Outcome
• Hip Prosthesis/adverse effects
• Arthritis, Infectious/surgery
• Reoperation/methods
• Anti-Bacterial Agents/therapeutic use
• Debridement

• PJI
• arthroplasty
• infection
• knee
• revision

• Humans
• Arthroplasty, Replacement, Knee/adverse effects
• Treatment Outcome
• Prosthesis-Related Infections/epidemiology
• Prosthesis-Related Infections/etiology
• Prosthesis-Related Infections/surgery
• Retrospective Studies
• Reoperation/adverse effects
• Debridement/adverse effects
• Anti-Bacterial Agents/therapeutic use
• Arthritis, Infectious/etiology

• marker
• periprosthetic joint infection
• serum
• synovial fluid

• PJI
• arthroplasty
• complication
• infection
• revision

• arthroplasty
• biomarkers
• joint infection
• periprosthetic
• synovial culture

• Humans
• Prosthesis-Related Infections/etiology
• Synovial Fluid
• Biomarkers
• Arthroplasty, Replacement, Knee/adverse effects
• Arthroplasty, Replacement, Hip/adverse effects
• Arthritis, Infectious/diagnosis

• Diagnostics
• Revision surgery
• Spinal instrumentation infection
• Treatment

• Shoulder arthroplasty
• periprosthetic joint infection
• revision shoulder arthroplasty

• Bayesian meta-analysis
• Fracture-related infection
• Nuclear imaging

• Bayes Theorem
• Fluorodeoxyglucose F18
• Fractures, Bone/complications
• Fractures, Bone/diagnostic imaging
• Humans
• Positron Emission Tomography Computed Tomography
• Wound Infection/diagnostic imaging
• Wound Infection/etiology

• 201808080126 China Sponsorship Council
• tsqn201909183 Young Taishan Scholars Program of Shandong Province

• CD15 focus score
• Eradication of infection
• Periprosthetic joint infection
• SLIM-Classification
• Two-stage revision arthroplasty

• infection eradication
• periprosthetic joint infection
• reimplantation
• revision shoulder arthroplasty
• total shoulder arthroplasty
• total shoulder replacement
• two-stage revision arthroplasty

• Decision analysis
• Irrigation and debridement
• Periprosthetic joint infection
• Total joint arthroplasty

• infected total knee arthroplasty
• periprosthetic infection
• trends

• Arthroplasty
• D-dimer
• Diagnosis
• Meta-analysis
• Periprosthetic joint infection

• Aseptic loosening
• Knee
• Knee arthroplasty
• Periprosthetic joint infection

The alpha-defensin lateral flow (ADLF) test is a new diagnostic tool for periprosthetic joint infection (PJI). Test accuracy for combined cohorts of hip and knee PJI has been reported to be good.

To assess the accuracy of the ADLF test for hip PJI, and to compare three different diagnostic criteria for PJI.

A cohort of 52 patients was identified, with a painful or poorly functioning total hip- or hemi-arthroplasty, that underwent aspiration and a subsequent ADLF test. PJI was diagnosed with Musculoskeletal Infection Society (MSIS) criteria, and sensitivity, specificity, overall accuracy, positive predictive value and negative predictive value were calculated. Furthermore, test specifics were compared with the European Bone and Joint Infection Society (EBJIS) and 2018 International Consensus Meeting (ICM) criteria for PJI.

Using MSIS criteria, sensitivity was 100% (CI: 54%-100%) and specificity was 89% (CI: 76%-96%). Six true positives and 5 false positives were found, including one case of metallosis. Using EBJIS criteria, more PJIs were found (11 vs 6), sensitivity was lower (71%, CI: 42%-92%) and specificity was higher (97%, CI: 86%-100%), with 4 false negatives and one false positive result. Using 2018 ICM criteria, sensitivity was 91% (62%-100%) and specificity 100% (91%-100%). The results in this cohort are comparable to previous studies.

Overall test accuracy of the ADLF test was good in this cohort, with a sensitivity of 100% and specificity of 89%. Using different PJI definition criteria, sensitivity and specificity changed slightly but overall accuracy remained around 90%. Using the ADLF test in metallosis cases can result in false positive results and should be performed with caution.

• Periprosthetic
• Arthroplasty
• Replacement
• Hip
• Infection
• Periprosthetic joint infection
• Alpha-defensin
• Synovasure

The α-defensins (AD) present in synovial fluid have been regarded as constituting the most accurate periprosthetic joint infection (PJI) biomarker. The methods most commonly used for estimating AD as a biomarker are the qualitative Synovasure^® PJI tests, based on the technique of lateral flow, and quantitative enzyme-linked immunosorbent assay (ELISA). Here, we propose a novel test based on detecting α-defensins in synovial fluid by high-performance liquid chromatography (HPLC). Synovial fluid was collected from 157 patients diagnosed with PJI, infectious arthritis (IA), arthrosis, reactive arthritis, and rheumatoid arthritis. AD concentrations in the fluid were determined by HPLC, and these same samples were used for additional diagnostic analyses. The results were statistically processed to calculate cutoff concentrations for PJI and IA. HPLC testing showed a sensitivity of 94% and a specificity of 92% for diagnosis of PJI, and a sensitivity of 97% and a specificity of 87% for diagnosis of IA. Using HPLC, we detected in synovial fluid a combination of three α-defensins: human neutrophil peptides HNP1, HNP2, and HNP3. All measured AD concentration values shown in this work refer to the sum of these three individual concentrations. Our study shows that the HPLC method meets the conditions for measuring precise concentrations of the sum of AD and can be recommended as part of a diagnostic array for PJI and IA diagnostics. By this method, we have verified that higher levels of AD in synovial fluid can also be seen in rheumatoid illnesses, crystal arthropathies, and reactive arthritis.

• HPLC
• arthrosis
• infectious arthritis
• periprosthetic joint infections
• synovial fluids biomarkers
• α-defensins

Prosthetic hip and knee joint infections (PJIs) are challenging to eradicate despite prosthesis removal and antibiotic therapy. There is a need to understand risk factors for PJI treatment failure in the setting of prosthesis removal.

A retrospective cohort of individuals who underwent prosthesis removal for a PJI at 5 hospitals in Toronto, Canada, from 2010 to 2014 was created. Treatment failure was defined as recurrent PJI, amputation, death, or chronic antibiotic suppression. Potential risk factors for treatment failure were abstracted by chart review and assessed using a Cox proportional hazards model.

A total of 533 individuals with prosthesis removal were followed for a median (interquartile range) of 814 (235–1530) days. A 1-stage exchange was performed in 19% (103/533), whereas a 2-stage procedure was completed in 88% (377/430). Treatment failure occurred in 24.8% (132/533) at 2 years; 53% (56/105) of recurrent PJIs were caused by a different bacterial species. At 4 years, treatment failure occurred in 36% of 1-stage and 32% of 2-stage procedures (P = .06). Characteristics associated with treatment failure included liver disease (adjusted hazard ratio [aHR], 3.12; 95% confidence interval [CI], 2.09–4.66), the presence of a sinus tract (aHR, 1.53; 95% CI, 1.12–2.10), preceding debridement with prosthesis retention (aHR, 1.68; 95% CI, 1.13–2.51), a 1-stage procedure (aHR, 1.72; 95% CI, 1.28–2.32), and infection due to Gram-negative bacilli (aHR, 1.35; 95% CI, 1.04–1.76).

Failure of PJI therapy is common, and risk factors are not easily modified. Improvements in treatment paradigms are needed, along with efforts to reduce orthopedic surgical site infections.

• prosthetic joint infection
• revision arthroplasty
• surgical site infection

• Infection board
• PJI
• antibiotic stewardship
• interdisciplinary
• prosthetic joint infections

Periprosthetic joint infection (PJI) is a serious complication occurring in 1% to 2% of primary arthroplasties, which is associated with high morbidity and need for complex interdisciplinary treatment strategies.

Cite this article: EFORT Open Rev 2019;4:482-494. DOI: 10.1302/2058-5241.4.180092

• arthroplasty
• biofilm
• diagnosis
• periprosthetic joint infection
• treatment

Irrigation is the cornerstone of treating skeletal infection by eliminating pathogens in wounds. A previous study shows that irrigation with normal saline (0.9%) and ethylenediaminetetraacetic acid (EDTA) could improve the removal of Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) compared with normal saline (NS) alone. However, it is still unclear whether EDTA solution is effective against infection with drug-resistant bacteria.

We established three wound infection models (skin defect, bone-exposed, implant-exposed) by inoculating the wounds with a variety of representative drug-resistant bacteria including methicillin-resistant S. aureus (MRSA), extended spectrum beta-lactamase-producing E. coli (ESBL-EC), multidrug-resistant Pseudomonas aeruginosa (MRPA), vancomycin-resistant Enterococcus (VRE), multidrug-resistant Acinetobacter baumannii (MRAB), multidrug-resistant Enterobacter (MRE), and multidrug-resistant Proteus mirabilis (MRPM). Irrigation and debridement were repeated until the wound culture became negative. The operating times required to eliminate pathogens in wounds were compared through survival analysis.

Compared with other groups (NS, castile soap, benzalkonium chloride, and bacitracin), the EDTA group required fewer debridement and irrigation operations to achieve pathogen eradication in all three models of wound infection.

Irrigation with EDTA solution was more effective than the other irrigation fluids used in the treatment of wound infections caused by drug-resistant pathogens.

Cite this article: Z. Deng, F. Liu, C. Li. Therapeutic effect of ethylenediaminetetraacetic acid irrigation solution against wound infection with drug-resistant bacteria in a rat model: an animal study. Bone Joint Res 2019;8:189–198. DOI: 10.1302/2046-3758.85.BJR-2018-0280.R3.

• Irrigation solution
• Open fracture
• Wound infection

• accuracy
• alpha-defensin
• area under the curve (AUC)
• c-reactive protein (CRP)
• cultures
• diagnosis
• erythrocyte sedimentation rate (ESR)
• gram stain
• host factors
• immunocompromised state
• inflammatory arthritis
• interleukins (Ils)
• laboratory testing
• negative cultures
• negative predictive value
• polymorphonuclear neutrophils (PMN) percentage
• positive predictive value
• prior antibiotic use
• procalcitonin (PCT)
• sensitivity
• serum D-dimer
• serum biomarkers
• specificity
• synovial biomarkers
• thresholds
• type of organism
• white blood cell count
• α-defensin

Arthrofibrosis after total knee arthroplasty represents a considerable burden for the patient and a therapeutic challenge for the practitioner. One possible cause discussed in the literature is a low-grade infection. This hypothesis should be examined within the scope of this retrospective study.

Nineteen patients with clinical symptoms of arthrofibrosis after primary total knee arthroplasty were examined between January, 1999 and January, 2012. Incorrect positioning was radiologically ruled out. All patients were examined clinically (score of Freeman as well as Blauth and Jäger), radiologically (component and leg alignment, patella height according to Insall and Salvati), microbiologically (culture-based procedures), molecular biologically (PCR) and histologically in the course of an open revision of the prosthesis.

According to the score of Freeman et al. (1977), a highly significant improvement in pain (p = 0.007) and in the overall score (p = 0.003) was shown. The knee joint mobility did not change significantly (p = 0.795). PCR was negative in 17 patients. One patient showed a PCR-positive result of the synovial membrane for Corynebacterium spp., while Staphylococcus warneri was detected in the culture. Another patient had a positive result of synovia PCR for Enterococcus cecorum as well as Corynebacterium spp. However, this culture was sterile. In 16 patient samples, no bacterial growth was detectable. Two samples were not evaluable. The main histopathological findings were synovialitis and fibrosis.

The hypothesis of low-grade-infection-induced arthrofibrosis after total knee arthroplasty could not be confirmed in this study. However, based on this small study population the conclusion needs to be confirmed by new and larger studies, ideally prospectively designed including a control group.

• Arthrofibrosis
• PCR
• Total knee arthroplasty

• Aseptic loosening
• Periprosthetic joint infection
• Total hip arthroplasty

Septic arthritis is a dangerous medical condition associated with significant morbidity and mortality. However, the differential diagnosis can be broad with conditions that mimic this disease and require different evaluation and treatment. This narrative review presents the emergency medicine evaluation and management, as well as important medical conditions that may mimic this disease. Septic arthritis commonly presents with monoarticular joint pain with erythema, warmth, swelling, and pain on palpation and movement. Fever is present in many patients, though most are low grade. Blood testing and imaging may assist with the diagnosis, but the gold standard is joint aspiration. Management includes intravenous antibiotics and orthopedic surgery consult for operative management vs. serial aspirations. Clinicians should consider mimics, such as abscess, avascular necrosis, cellulitis, crystal-induced arthropathies, Lyme disease, malignancy, osteomyelitis, reactive arthritis, rheumatoid arthritis, and transient synovitis. While monoarticular arthritis can be due to septic arthritis, other medical and surgical conditions present similarly and require different management. It is essential for the emergency clinician to be aware how to diagnose and treat these mimics.

• C-reactive protein
• Diagnostic
• Low virulence
• Prosthetic joint infection

Two-stage revision is the gold standard for the treatment of deep implant infection after knee or hip arthroplasty. Irrigation and debridement may be a treatment option for failed 2-stage revisions in cases where a reinfection occurs within 30 days or the symptoms exist not longer than 3 weeks and is appealing because of its low morbidity. We determined the incidence of recurrent infections following irrigation and debridement for failed two-stage revision hip and knee arthroplasty.

We performed a single center retrospective review of periprosthetic hip and knee infections treated with a two-stage procedure from 2002 to 2010. All patients that subsequently underwent irrigation and debridement for a subsequent infection were selected for the current study.

440 two-stage revisions were performed between 2002 and 2010. Fifty-one two-stage revisions failed (11.6%). Nineteen failed two-stage revisions were treated with irrigation and debridement; 12 (63.2%) patients remained free of infection at follow-up (mean follow-up: 39 months; range, 24-90 months), infection persisted in 6 patients (31.6%), and 1 patient died (5.3%).

Success rates of irrigation and debridement for failed two-stage procedures are similar to the success rates of irrigation and debridement in primary implant infections. According to the current paper, irrigation and debridement are an acceptable treatment for acute reinfections after failed two-stage revision if performed within the first 30 postoperative days after failed two-stage procedure or if symptoms are present for less than 3 weeks in the presence of a susceptible organism.

• Corticosteroid
• Infection
• PONV
• Postoperative nausea
• Prosthetic joint infection
• Risk factor

• functional outcome
• hip
• one-stage revision
• outcome
• periprosthetic joint infection
• quality of life

• MSIS criteria
• biomarker
• periprosthetic joint infection
• total hip arthroplasty
• total knee arthroplasty
• α-defensin

• Arthritis, Infectious/surgery
• Arthroplasty, Replacement, Hip/adverse effects
• Arthroplasty, Replacement, Knee/adverse effects
• Biomarkers
• Diagnostic Tests, Routine
• Humans
• Predictive Value of Tests
• Prospective Studies
• Prosthesis-Related Infections/diagnosis
• Prosthesis-Related Infections/surgery
• Reoperation
• Retrospective Studies
• Sensitivity and Specificity
• Synovial Fluid
• Treatment Outcome
• alpha-Defensins/analysis

• Biomarkers
• Diagnosis
• Periprosthetic joint infection
• Serum
• Synovial fluid

• Candida
• arthroplasty
• methicillin-resistant Staphylococcus aureus
• prosthetic joint infection

Coagulase-negative staphylococci (CoNS) are the main pathogens responsible for prosthetic joint infections (PJIs). As normal inhabitants of human skin, it is often difficult to define if they are contaminants, or if they have an active role in initiating infection. This study aims to evaluate differences in CoNS organisms (Staphylococcus hominis, Staphylococcus capitis, Staphylococcus haemolyticus, Staphylococcus warneri) and Staphylococcus aureus in terms of isolation rate and antimicrobial susceptibility from patients who met the International Consensus Meeting (ICM) criteria for PJIs and those who did not.

Staphylococci isolates from January 2014 to December 2015 retrieved from patients undergoing revision joint arthroplasty were classified in accordance with criteria established by the ICM of Philadelphia.

As per the consensus classification, 50 CoNS and 39 S. aureus infections were recognized as pathogens, while 16 CoNS and four S. aureus were considered as contaminants. Frequency of isolation of S. aureus was significantly higher in infected patients than in those without infection, while no significant differences were observed among CoNS. Resistance to levofloxacin, erythromycin, gentamicin trimethoprim/sulfamethoxazole, and rifampicin was significantly more frequent in S. haemolyticus than in the other species, as well as resistance to erythromycin and gentamicin in S. hominis. In comparison to S. aureus, CoNS were significantly more resistant to daptomycin and gentamicin and more susceptible to rifampicin.

CoNS, other than Staphylococcus epidermidis, are frequently isolated from PJIs, and their infective role and antimicrobial susceptibility need to be assessed on an individual patient basis. S. haemolyticus seems to emerge as responsible for PJI in a large volume of patients, and its role needs to be further investigated, also considering its pattern of resistance.

• Staphylococcus aureus
• Staphylococcus capitis
• Staphylococcus haemolyticus
• Staphylococcus hominis
• Staphylococcus warneri
• antibiotics susceptibility
• periprosthetic joint infections

• Diagnosis
• Healthcare-associated infections
• Prosthetic joint infection
• Surveillance

• Aged
• Diagnostic Techniques and Procedures
• Female
• Humans
• Male
• Practice Guidelines as Topic
• Predictive Value of Tests
• Prosthesis-Related Infections/diagnosis
• Prosthesis-Related Infections/microbiology
• Prosthesis-Related Infections/parasitology

Periprosthetic joint infection (PJI) is considered one of the most challenging complications compromising patient health and is considered an economic burden. Despite all strategies PJI prevalence is between 1%-2%. Considerable efforts have been investigated in the past decade to diminish or erradicate PJI prevalence. This article manages the definition of PJI and the new major and minor criteria from Parvizi et al Then a scientific analysis of every minor and major criteria. Multidisciplinary management is reccommended according to guidelines. A numerous of surgical options exist each and everyone with its indications, contraindications and specific antibiotic therapy regimen. Surgical options are: (1) irrigation and cleaning with retention of the prosthesis with a success rate 0%-89%; (2) single-stage revision surgery with a succes rate of > 80%; and (3) two-stage revision surgery (authors preferred method) with a succes rate of 87%. Radical treatment options like arthrodesis and amputation are reserved for specific group of patients, with a succes rate varying from 60%-100%. The future of PJI is focused on improving the diagnostic tools and to combat biofilm. The cornerstone of management consists in a rapid diagnosis and specific therapy. This article presents the most current diagnostic and treatment criteria as well as the different surgical treatment options depending on the type of infection, bacterial virulence and patient comorbidities.

• Periprosthesic joint infection
• Arthroplasty
• Arthrocentesis
• Infection
• Diagnosis
• Staphylococcus aureus

• Immunosuppressive therapy
• Infection
• Rheumatoid arthritis
• Rheumatology
• Risc factor
• Total joint arthroplasty

• Guidelines
• Periprosthetic joint infection
• Prevention
• Surgical site infection

• CD15 focus score
• Low-virulence and high-virulence microbial pathogens
• Neutrophilic granulocytes
• Periprosthetic joint infection

Periprosthetic infection is one of the main reasons for revision surgery after hip arthroplasty. The purpose of the present study is to compare the reliability of triple-phase bone scintigraphy (TPBS) in the diagnosis of periprosthetic infection between cementless total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA).

In this retrospective study, 52 patients were analyzed; 33 of them were performed with THA and 19 of them were performed with BHA. The exclusion criteria were cementation in previous surgery, romatological joint disorders, periprosthetic fracture and malignancy history. C reactive protein (CRP) and erythrocyte sedimentation (ESR) rate results were recorded preoperatively. Tissue samples from the different areas periprosthetic tissue were obtained for histopathological examination and sample tissue culture.

In the present study, the sensitivity, specificity and accuracy were 90.9%, 77.3% and 81.8%, respectively, for THA and 77.8%, 60.0% and 68.4%, respectively, for BHA. Positive predictive values for THA and BHA were 66.7% and 63.6%, and negative predictive values were 94.4% and 75.0%, respectively.

Due to the higher sensitivity, specificity and accuracy, TPBS has a more reliable diagnostic value for cementless THA in the diagnosis of periprosthetic infection compared to cementless BHA.

•

Triple-phase bone scintigraphy is effective in ruling out infection with its higher sensitivity.

• Hemiarthroplasty
• Hip arthroplasty
• Revision
• Triple-phase bone scintigraphy

• Adverse reaction
• Allergic reaction
• Classification
• Implants
• Synovitis

• Diagnosis, Differential
• Foreign-Body Reaction/etiology
• Foreign-Body Reaction/pathology
• Humans
• Hypersensitivity/etiology
• Hypersensitivity/immunology
• Hypersensitivity/pathology
• Joint Prosthesis/adverse effects
• Metals/adverse effects
• Prosthesis-Related Infections/etiology
• Prosthesis-Related Infections/pathology

• Irrigation and Debridement
• One-stage revision
• Periprosthetic Joint Infection
• Total Knee Arthroplasty
• Two-Stage revision

Vitamin D deficiency has been associated with a high number of health outcomes, and its role on the immune system has been deeply investigated in recent years, although poor data are still available on vitamin D status in orthopedic infections including those of prosthetic implants.

We focused on preoperative values of 25(OH)D in selected groups of patients with septic (Group A) or aseptic (Group B) prosthetic loosening, infective bone disease such as septic arthritis and osteomyelitis (Group C) and other orthopedic pathologies (Group D) to evaluate differences in the vitamin D status.

A high prevalence of vitamin D deficiency was recorded among the study population (16.5 ± 5.4 ng/mL, mean ± SD). Interestingly, all patients with an infection presented a higher 25(OH)D concentration (17.7 ± 5.3 ng/mL) in respect to uninfected ones (15.1 ± 5.6 ng/mL). Significantly higher levels of 25(OH)D were observed in patients with prosthetic joint infection (18.5 ± 6.5 ng/mL), when compared with those presenting an aseptic loosening (13.6 ± 9.4 ng/mL).

Deficiency in vitamin D levels have been found in orthopaedic patients. Prosthetic joint infections seems to be associated to higher values of vitamin D in respect to other bone infections or to other orthopaedic conditions requiring surgery.

More studies are needed to improve the knowledge on vitamin D status in these patients and to better clarify the role of vitamin D in relation to osteoarticular infections.