Aim. Analysis of microbiological spectrum and resistance patterns as well as the clinical outcome of patients who underwent a Debridement, antibiotics and implant retention (DAIR) procedure in the early phase following failed two-stage exchange arthroplasty of the knee and hip. Method. Of 312 patients treated with two-stage exchange arthroplasty between January 2011 and December 2019, 16 (5.1%) patients (9 knee, 7 hip) underwent a DAIR procedure within 6 months following second stage. We retrospectively analyzed the microbiological results as well as changes in the microbiological spectrum and antibiotic resistance patterns between stages of two-stage exchange arthroplasties and DAIR procedures. Patient's re-revision rates after a minimum follow-up of 12 months following DAIR procedure were evaluated. Moreover, differences between knee and hip and between infected primary total joint replacement (TJRs) and infected revision TJRs as well as patient's host factors and microbiological results regarding the outcome of DAIR were analyzed. Results. In 7/16 (43.8%) patients the first and second stage procedure was culture positive, in 5/16 (31.2%) patients the first and second stage procedure was culture negative and in 4/16 (25%) patients the first stage procedure was culture positive, and the second stage procedure was culture negative. Moreover, 6 (37.5%) out of 16 DAIR procedures showed a positive microbiological result. In 5/7 (71.4%) patients with culture positive second stage procedure a different microorganism compared to first stage procedure was detected. In 6/6 (100%) patients with culture positive DAIR procedure, the isolated microorganisms were not detected during first or second stage procedure. An additional re-revision surgery was necessary in 4/16 (25%) patients after a median time of 31 months (range, 12 to 138 months) at a mean follow up of 63.1 ± 32 months following DAIR procedure. Highest re-revision rates were found in patients with culture positive second stage procedures (3/7 [42.9%]) and patients with culture positive DAIR procedures (2/6 [33.3%]). Conclusions. DAIR procedure seems to be a useful early treatment option following failed two-stage exchange arthroplasty. The re-revision rates were independent of different combinations of culture positive and culture negative first and second stage procedures. The high number of changes in the microbiological spectrum needs to be considered in the treatment of PJI

Introduction. Our objective is to describe early and midterm results with the use of a new knee prosthesis as an articulating spacer in planned two-stage management for infected total knee arthroplasty. As a second objective, we compared outcomes between the group with a retained first stage and those with a completed 2-stage revision. Methods. Forty-seven patients (48 knees) from January 2012 and November 2017 underwent a 2-stage exchange with an articulating spacer with new implants was used for a chronic knee periprosthetic joint infection with a mean follow-up of 3.7 years (2–6.5 years). The most frequently identified infecting organism was MSSA (31%), MRSA (21%) or MRSE (20%). At the first stage, a new PS femoral component and a new all-polyethylene posterior stabilized (PS) tibial component or a standard PS tibial liner were cemented with antibiotic-cement, typically 3.6 gm tobramycin and vancomycin 1.5 gm. IV antibiotics for six weeks were administered. The planned reimplantation was at 3 months, but ninetteen spacers (14 all poly tibias and 5 tibial liner) were retained for over 12 months. Postoperative assessment included knee range of motion (ROM), quality of life (QOL) scores (SF-12, WOMAC, KOOS, Oxford, and UCLA scores), and a satisfaction scale from 0–100%. Results. Of the 48 knees, 8 failed due to lack of infection control, and 2 died within the first year for medical reasons (4%), giving a failure rate of 17% (8/46). One of these knees was not revised due to poor medical status. Of the remaining 7, 2 had a repeat 2-stage exchange, one a single stage revision and 4 irrigation and debridement with retained implants. All 7 had a successful outcome with infection control after this, leaving a permanent failure rate of 2% (1/46). Five of the 19 knees with initially retained implants were revised to a second stage after 12 months for continued pain or instability (1/14 all poly tibia and 4/5 PS liner). There were no significant differences in final range of motion or QOL scores between patients with a retained first stage procedure and those who underwent a second stage operation. Also, there was no statistically significant difference in the initial failure rate due to infection between patients with a complete 2-stage revision and those with a retained first stage (19% (6/31) vs. 14% (2/14), respectively; p=0.613). Conclusions. When an all poly tibial implant is used a spacer in two-stage exchange arthroplasty, it may be retained for over 12 months, with no difference in infection control, range of motion, and quality of life assessment to patients with complete 2-stage revision surgery. With this technique, the second stage may be delayed in patients who are doing well, and may never need to be revised, hence we propose the new term “one-and-a-half stage exchange”

It is strongly recommended that tissue and synovial fluid culture samples be obtained during reimplantation performed as part of a two-stage exchange arthroplasty. The incidence of positive cultures during reimplantation and the influence of positive cultures on subsequent outcome are unknown. This aim of this study was to determine the incidence of positive cultures during reimplantation and to investigate the association between positive cultures at reimplantation and the subsequent outcome. A retrospective review was conducted on 267 patients that met the Musculoskeletal Infection Society (MSIS) criteria for PJI that completed both stages of two-stage exchange arthroplasty (Table 1). Intraoperative culture results from tissue and/or synovial fluid were obtained. Cultures were positive in 33 cases (12.4%) undergoing reimplantation surgery (Figure 1). Treatment failure was assessed based on the Delphi consensus definition. Logistic regression analysis was performed to assess the predictors of positive culture and risk factors for failure of two-stage exchange arthroplasty. Treatment failure was 45.5% for those with a positive intraoperative culture and 20.9% in those with negative cultures at the time of reimplantation. When controlling for organism virulence, comorbidities, and other confounding factors, treatment failure was higher (odds ratio [OR]: 3.3; 95% confidence interval [CI]: 1.3–4.5) and occurred at an earlier time point (hazard ratio: 2.5; 95% CI: 1.3–4.5) in patients with a positive reimplantation culture. The treatment failure rate was not different between cases with two or more positive cultures (36.4%) and one positive culture (42.8%). Positive intraoperative cultures during reimplantation, regardless of the number of positive samples were independently associated with two times the risk of subsequent infection and earlier treatment failure. Surgeons should be aware that a positive culture at the time of reimplantation independently increases the risk of subsequent failure and needs to be taken seriously. Given the significance of these findings, future studies are needed to evaluate the optimal management of positive cultures during reimplantation surgery

Aim. The purpose of this work is to study whether there is or not, in the case of an aseptic arthroplasty exchange, a relationship between positive cultures and an early periprosthetic joint infection. Method. We carried out a retrospective review of our cases of aseptic exchange arthroplasties of hip, knee and shoulder performed between January 2007 and December 2015. The follow-up period was, in average, from 1 to 9 years, and in all the cases perioperative cultures were evaluated. Results. The number of arthroplasties reviewed was 183, corresponding to 180 patients. Seventy-six cultures were positive for one or more microorganisms. Staphylococcus epidermidis was the microorganism most isolated followed by other Coagulase Negative Staphylococci. Five cases (6.58%) were followed by an acute infection. In three of these cases (60%) the previous culture were positive, but only in one single case, one of the microorganisms isolated after the infection was the same as the isolated previously. Conclusions. Perioperative cultures in aseptic exchange arthroplasties seems not to have any value as infection predictor. Neither the previous isolated microorganisms, in case of postoperative infection, have any value as a predictor of the etiological agent

Purpose: The gold standard for treatment of infected total hip or knee replacements remains a 2-stage exchange arthroplasty. This includes aggressive irrigation and debridement, implant removal, insertion of antibiotic impregnated spacers, iv antibiotics, and eventual reimplantion with a definitive prosthesis. The purpose of this study was to quantify Vancomycin and Gentamycin synovial fluid levels at the time of reimplantation following a 2-stage exchange arthroplasty for a infected total hip or knee replacements. Methods: The senior author performed 42 two-stage reconstructions using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC). Each 40g bag of Pala-cos-R cement was impregnated with Vancomycin 2g, Gentamycin 4.8g, and plus/minus ancef 2.0g (depending on penicillin allergy). At the time of reimplantation, the synovial fluid was immediately analyzed for levels of Vancomycin and Gentamycin. Results: 17 patients were taken for stage II within 60 days (avg. 53). The synovial fluid vancomycin and gentamycin levels were 12.7 and 20.6 respectively. Twelve patients had stage II between 60 and 90 days (avg. 79). The synovial fluid vancomycin and gentamycin levels were 6.2 and 14.9 respectively. The remaining 13 patients underwent stage II beyond 90 days (avg. 192), and their synovial fluid vancomycin and gentamycin levels were 3.3 and 2.4 respectively. 40 of 42 patients had their infections eradicated. Conclusions: in vitro evidence predicts that antibiotics elute rapidly from bone cement. The results of this study confirm that substantial doses of vancomycin, gentamycin, and ancef per bag of Palacos-R cement does confer long term synovial fluid antibiotic levels well above the minimal inhibitory concentrations required to treat infected total joints. When stage II reimplantation is done at greater than 3 months, synovial fluid antibiotic levels decline significantly

The incidence of periprosthetic knee infection is generally low (0.5%–2%) but the economic impact is great. The rates are higher for rheumatoid arthritis and revision knee surgery. Treatment of periprosthetic knee infection takes into account the acuteness of the infection, the overall immune/medical status of the patient, and the local factors at the site of infection. Evaluate the results of two-phase exchange arthroplasty with the use of articulating spacer in III-A-1 and III-B-1 periprosthetic knee infection. From 1990–2005, 24 patients with minimum (< 2) systemic and no local compromising factors were treated for chronic periprosthetic knee infection. These patients staged as III-A-1 or III-B-1 according to MSIS staging system. Diagnosis was clinical, radiological, laboratory and from knee aspiration cultures. Two-phase exchange arthroplasty was performed. Initially, there was removal of the prosthesis, surgical debridement and placement of a PMMA spacer impregnated with antibiotic. The spacer was shaped as a knee joint permitting motion. In 6 cases a hybrid spacer was used (PMMA and TECRES® spacer). Intravenous antibiotic therapy according to intraoperative cultures followed for 6–8 weeks. Re-implantation was always done after the completion of the antibiotic therapy and on the ground of normal CRP, ESR and negative aspiration cultures. All patients received antibiotics after the re-implantation. Staphylococcus aureus was the most common pathogen followed by Staphylococcus epidermidis and Pseudomonas aeruginosa. No infection recurrence was noted over a 2–15 years follow-up. All patients returned to normal everyday activity. A custom-made prosthesis was placed in one patient and there was a rupture of the extensor mechanism in another. Patients with periprosthetic knee infection, staged as III-A-1 and III-B-1, when treated with two-stage exchange arthroplasty combined with antibiotic impregnated articulating spacer and i.v. antibiotics can have excellent results

Introduction: The use of prolonged courses of parenteral or oral antibiotic therapy in combination with a two-stage exchange procedure in the management of the infected total hip arthroplasty is reported by many major series.

Methods: We present a series of 114 patients, all with microbiologically proven chronic deep infection, treated with a two-stage exchange with antibiotic loaded cement and where a prolonged course of antibiotic therapy has not been used. The mean follow-up for all patients is 74months (range 2–175months) with all surviving patients having a minimum 2 year follow-up.

Results: Infection was successfully eradicated in 100 patients (88%). The infection cure rate in our series is similar to that reported elsewhere where prolonged adjuvant antibiotic therapy was used.

Discussion: Using the technique described a prolonged course of systemic antibiotics does not appear to be necessary; the high costs of antibiotic administration, both to the patient and care facility are not incurred.

The relative advantages and disadvantages of two-stage versus one-stage management of infected total hip arthroplasties are the current subject of intense debate. To understand the merits of each approach detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of this study was to assess the long-term results of two-stage exchange arthroplasty for THAs in one of the largest series to date. We identified 331 infected THAs treated with a two-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had prior treatment for infection. Mean age at reimplantation was 66 years, 38% were female, and mean BMI was 30 kg/m. 2. PJI diagnosis was based on the 2011 MSIS criteria. A competing risk model accounting for death was utilized. Mean follow up was 8 years. The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI>30 kg/m. 2. (HR 2; p=0.049), and need for a spacer exchange (HR 3.2; p=0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years; 45% required revision). Factors predictive of dislocation were female sex (HR 2; p=0.047) and BMI<30 kg/m. 2. (HR 3; p=0.02). The mean HHS improved from 54 to 75 at 10 years. In this series of 331 two-stage exchange arthroplasties performed for infected hips, we found a low aseptic revision rate (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to one-stage exchanges. Level of Evidence: Level III

Two-stage exchange arthroplasty is traditionally used to treat periprosthetic hip infection. Nevertheless, particularly in high-risk patients, there has been increased attention towards alternatives such as 1.5-stage exchange arthroplasty which takes place in one surgery. Therefore, we sought to compare (1) operative time, length-of-stay (LOS), transfusions, (2) causative organism identification and polymicrobial infection rates, (3) re-revision rates and re-revision reasons, (4) mortality, and determine (5) independent predictors of re-revision. Retrospective chart review of 71 patients who underwent either 1.5- (n=38) or 2-stage (n=33) exchange hip arthroplasty at a single institution (03/2019-05/2023). Demographics, surgical, inpatient, and infection characteristics were noted. Main outcomes evaluated were re-revision rates, re-revision reasons, mortality, and cause of death. Independent predictors of re-revision were assessed utilizing logistic regression. Mean follow: 675 days (range, 23–1,715). Demographics were not significantly different except for a higher proportion of 1.5-stage patients classified as American-Society-of-Anesthesiologists (ASA) status 3 or 4 (84.2 vs. 48.5%, p=0.002). Length of follow-up was significantly longer in the 2-stage group (924.4 vs. 458 days, p<0.001) as well as operative time (506 vs. 271 minutes, p<0.001). In the 1.5-stage group, there was a higher proportion of polymicrobial infections (23.7 vs. 3.0%, p=0.016), re-revision rates (28.9 vs. 9.1%, p=0.042) and periprosthetic infections as a cause of revision (90.9 vs. 0%, p=0.007). Mortality rates were not significantly different, and no patient died for causes related to infection. Type of surgery (1.5-stage vs. 2-stage) was the only independent predictor of re-revision (odds-ratio 4.0, 95% confidence-interval 1.02–16.16, p=0.046). Our data suggests that patients who undergo 1.5-stage exchange arthroplasty have a significantly higher re-revision rate (mostly due to infection) when compared to 2-stage patients. We acknowledge potential benefits of the 1.5-stage strategy, especially in high-risk patients since it involves single surgery. However, higher re-revision rates must be considered when counseling patients

Purpose. Management and outcomes of fungal periprosthetic joint infection (PJI) remain unclear due to its rarity. Although two-stage exchange arthroplasty is considered a treatment of choice for its chronic features, there is no consensus for local use of antifungal agent at the 1st stage surgery. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer in two-stage exchange arthroplasty against chronic fungal PJIs after total knee arthroplasty (TKA). Methods. Nine patients who were diagnosed and treated for chronic fungal PJIs after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, amphotericin-impregnated cement spacer was inserted for all patients. Systemic antifungal medication was used during the interval between two stage operations. Patients were followed up for more than 2 years after exchange arthroplasty and their medical records were reviewed. Results. The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, 5 to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by preoperative joint aspiration culture in 6 cases. For the other 3 cases, it was confirmed by open debridement tissue culture. All infections were caused by Candida parapsilosis except for one case which was caused by Candida pelliculosa. The average number of operations before exchange arthroplasty to solve the infection was 2.7 times (range, 1 to 5 times). Average duration of antifungal agent use confirmed by sensitivity test was 7 months (range, 4 to 15 months). Mean interval between two stage operation was 6 months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months). Conclusions. Due to its ill-defined symptoms and inconclusive blood test, fungal PJI after TKA is difficult to diagnose and has a prolonged clinical course. Two-stage exchange arthroplasty with antifungal-impregnated cement spacer is a very effective strategy with excellent outcome

The method of choice in the management of chronic infections is the exchange arthroplasty. The exchange arthroplasty can be performed either in a one- or in a two-stage setting, whereas the two-stage exchange arthroplasty is still considered the “gold standard” worldwide. The current literature and guidelines for PJI treatment deliver no clear evidence that a two-stage exchange procedure has a clearly higher success rate than the one-stage procedure. Since the first implantation of mixing antibiotics into bone cement in 1970s, the ENDO-Klinik followed until today in over 85% of all infected cases the one-stage exchange arthroplasty for the management of PJI. The main requirement is the known germ with known susceptibility based on microbiological diagnostics. Proper bone stock for cemented, in some cases, uncemented reconstruction, and the possibility of primary wound closure are also clear assumptions. The one-stage exchange arthroplasty delivers diverse advantages. For instance, the need for only one operation, shorter hospitalization, reduced systemic antibiotics and lower overall cost. A well-defined pre-operative planning regime is absolutely mandatory

Introduction. Two-stage exchange arthroplasty remains the gold standard for treatment of PJI with reported success rates of 85–90%. Complications that occur during treatment are often not reported or considered in the success rate. The purpose of this study was to analyze complications in patients undergoing two-stage exchange and determine when they occur. Methods. We analyzed all patients that underwent two-stage exchange arthroplasty for treatment of chronic PJI of the knee from 2010 to 2018. We categorized complications as medical vs. surgical. The intervals for complications were divided into: interstage, early post re-implant (3 months) and late post re-implant (3 months to minimum 1 year). Minimum follow-up to evaluate complications was one year. Results. Overall, 132 patients underwent a first stage of a two-stage exchange. There were 63 males and 59 females with an average age at first stage surgery of 66.6 years (SD: 8.9). Ten patients (7.6%) did not undergo re-implantation following resection arthroplasty (8 retained spacers and 2 deaths). 122 patients underwent the planned second stage of a two-stage exchange arthroplasty of the knee. The overall success rate (re-implant without recurrence of infection) was 78%. Overall mortality was 1.6% at one year and 9% at 5 years after treatment. Fifty-six patients (46%) experienced at least one complication. 43 patients had an orthopaedic related complication that required additional surgery and 13 patients had a medical complication. 33% of the total complications occurred during the interstage period, 18% within 90 days of reimplant, and 37% greater than three months from reimplant (p=0.0287). Discussion. Reported rates of success of two stage exchanges for PJI have not traditionally considered complications in the definition of success. In our series, significant numbers of patients experienced complications, more often after reimplantation, highlighting the morbidity of this method of treatment and the need for in-depth patient counseling, careful surgical technique, and close follow up. For figures, tables, or references, please contact authors directly

Aim. Periprosthetic joint infection (PJI) is a devastating complication that develops after total joint arthroplasty (TJA) whose incidence is expected to increase over the years. Traditionally, surgical treatment of PJI has been based on algorithms, where early infections are preferably treated with debridement, antibiotics, and implant retention (DAIR), while late infections with two-stage revision surgery. Two-stage revision is considered the “gold standard” for treatment of chronic PJI. In this observational retrospective study, we investigated the potential role of inflammatory blood markers (neutrophil-to- lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory index (SII)], systemic inflammatory response index (SIRI), and aggregate index of systemic inflammation (AISI)) as prognostic factors in two-stage exchange arthroplasty for PJI. Method. A single-center retrospective analysis was conducted, collecting clinical data and laboratory parameters from patients submitted to prosthetic explantation for chronic PJI. Laboratory parameters (PCR, NLR, MLR, PLR, SIRI, SII and AISI) were evaluated at the explantation time, at 4, 6, 8 weeks after surgery and at reimplantation time. Correlation between laboratory parameters and surgery success was evaluated, defined as infection absence/resolution at the last follow up. Results. 57 patients with PJI were evaluated (62% males; average age 70 years, SD 12.14). Fifty-three patients with chronic PJI were included. Nineteen patients completed the two-stage revision process. Among them, none showed signs of re-infection or persistence of infection at the last available follow up. The other twenty-three patients did not replant due to persistent infection: among them, some (the most) underwent spacer retention; others were submitted to Girdlestone technique or chronic suppressive antibiotic therapy. Of the patients who concluded the two-stage revision, the ones with high SIRI values (mean 3.08 SD 1.7, p-value 0.04) and MLR values (mean 0.4 SD 0.2, p-value 0.02) at the explantation time were associated with a higher probability of infection resolution. Moreover, higher variation of SIRI and PCR, also defined respectively delta-SIRI (mean −2.3 SD 1.8, p-value 0.03) and delta-PCR (mean −46 SD 35.7, p-value 0.03), were associated with favorable outcomes. Conclusions. The results of our study suggest that, in patients with PJI undergoing two-stage, SIRI and MLR values and delta-SIRI and delta-PCR values could be predictive of favorable outcome. The evaluation of these laboratory indices, especially their determination at 4 weeks after removal, could therefore help to determine which patients could be successfully replanted and to identify the best time to replant

Abstract. Introduction. The prevalence of recurrent infection following two-stage exchange arthroplasty following failure of a total knee arthroplasty (TKA) has been reported to be 10% to 25%. There is limited literature available on repeat two stage revisions for TKA infection with only small cohorts and variable success rates. Methodology. A retrospective cohort study investigating the outcome of two stage revision arthroplasty for treatment of TKA infection was conducted with the aim of identifying factors linked to recurrence of infection. A consecutive cohort of all microbiology intra-operative periprosthetic knee samples from a single revision arthroplasty centre between January 2010 and December 2016 was identified. The final cohort consisted of 658 samples taken during 64 patients undergoing two stage revision knee surgery for infection. Patient demographics, medical and orthopaedic history data including post-operative outcomes and subsequent treatment was obtained from the electronic records system and medical notes. Results. 65.6% of the cohort (N=42) had successful eradication of their infection. For the twenty-two patients that had failure of their two stage revision, twenty patients had samples available from further surgical intervention. Sixteen patients (80%) had different organisms isolated when they had repeat surgical samples taken when compared to their first stage samples. Overall, for subsequent treatments there was a success rate of 75% if the same organism was identified and 62.5% if there were new isolated organisms. Conclusion. These findings may have implications for the treatment strategies chosen for re-infection after two stage TKA revisions if new causative organisms are isolated

Historical perspective: Irrigation and debridement (I&D) with modular exchange has historically been the recommended treatment for acute post-operative periprosthetic joint infection (PJI), and acute hematogenous PJI. The theory supporting this practice was that because the bacterial glycocalyx had not yet formed by these early time points, by simply debriding the intra-articular bacterial load and exchanging the modular parts, one could potentially eradicate the infection, retain the prior components, and minimise morbidity to the patient. More recently, literature is coming out suggesting that this may not necessarily be the case. The vast majority of published research on the outcomes following I&D for treatment of PJI has focused on either cohorts of total knee arthroplasty patients or combined cohorts of total hip and knee patients. For this reason, it is difficult to tease out the differential success rate of periprosthetic hip vs. knee infections. Sherrell et al. performed a systematic review of the existing literature and created a table detailing the failure rates for various published articles on I&D for periprosthetic TKA infection. Since it is the glycocalyx that has been thought to be the reason for treatment failure of many cases of PJI treated with I&D, many authors have implicated staphylococcal species as a predictor of a negative outcome with failure rates ranging from 30–35%. Methicillin resistant organisms have been shown to be particularly difficult to eradicate with an isolated I&D, with a 72–84% failure rate at 2 year follow-up. Interestingly, a recent study by Odum et al. suggests that neither the infecting microbe, nor the antibiotic resistance profile of the organism, as has been classically thought, actually predicts success of I&D. Previous reports have indicated that the ability of I&D to control infection is related to the duration of symptoms and its timing relative to the index surgery. However, more recent literature is coming out to support the contrary. Koyonos et al. reviewed the outcomes of a series of 138 cases of PJI treated with I&D based on acuity of infection and concluded that an I&D has a limited role in controlling PJI regardless of acuity. Intuitively, the physical health of the host/patient should influence the success of I&D for treatment of PJI. Several authors have shown that an immunocompromised state is a predictor of treatment failure. Furthermore, Azzam et al. reported that patients with a higher American Society of Anesthesia (ASA) score, a proxy of severity of medical comorbidities, had a significantly higher failure rate. Although potentially appealing due to relative ease of execution and minimal surgical morbidity, the ability to successfully eradicate infection with an arthroscopic procedure may be compromised. Given the inability to perform a radical surgical debridement, nor exchange modular components, arthroscopic debridement should be used with extreme reservation in any case of PJI, regardless of the host, nature of the infecting organism, or acuity of infection. I&D as a conservative, less morbid alternative to two-stage exchange - There is a growing body of literature to suggest that an I&D with modular component exchange may not be the benign, less morbid alternative to the ‘gold standard’ two-stage exchange arthroplasty. In fact, Fehring et al. has reported that the success of a two-stage antibiotic spacer exchange arthroplasty may be compromised by an initial I&D. They found that patients who were initially treated with an I&D only had a 66% chance of eradicating infection following a two-stage exchange arthroplasty, in contrast to historical reports of 80–90% success

Aim. Treatment of chronic prosthetic joint infection (PJI) combines exchange arthroplasty and effective antibiotic therapy. Staphylococci are the most frequent microorganism isolated in PJIs, with resistance to methicillin found in 15–50% of the cases. Data from randomized trials on treatment of methicillin-resistant staphylococci are lacking and the choice of antibiotic(s) and recommendations vary according to authors. To date, combination therapy including vancomycin is the treatment of choice. Minocycline, a cyclin antibiotic, is naturally effective against methicillin-resistant staphylococci. We use this antibiotic since many years in combination with vancomycin for the treatment of multi-drug resistant staphylococcal bone and joint infections. The aim of this study is to analyze the outcome of patients treated with combination antibiotic therapy including minocycline for the treatment of chronic methicillin-resistant staphylococcal PJI. Method. We conducted a cohort study between 2004 and 2014 in our referral center for bone and joint infections. Data were extracted from the prospective database. All the patients receiving an initial combination therapy including at least 4 weeks of minocycline, given orally, and another IV antibiotic, usually high-dose continuous IV vancomycin, for chronic MR staphylococcal PJI and who underwent one or two stage exchange arthroplasty, were included. They were followed prospectively for at least 2 years. Results. We included 42 patients: 26 patients (62%) had one-stage, 16 patients (38%) had two stage exchange arthroplasty. Median duration of IV and total antibiotic therapy was 42 [40–44] days and 84 [84–88] days, respectively. 41 patients (98%) received vancomycin as associated initial therapy. Thirty-six patients received 100mgx3 per day of minocycline. Six received >300mg per day because of low serum concentrations. Median follow-up was 48 months (IQR 27–58). Survival rate without infection was 84,5% at 2 years, 70.2% at 6 years. Four patients reported adverse events due to minocycline: one had grade 4 thrombopenia leading to minocycline withdrawal, two had grade 2 liver toxicity. One patient had grade 1 nauseas. Two patients with MR Staphylococcus epidermidis knee arthroplasty experienced relapse. Three patients with hip arthroplasty infection developed a new infection within 2 year due to MSSA, Pseudomonas aeruginosa, and plurimicrobial for the last one. Three further patients developed a new infection 3 (n=2) and 4 years later. They were all acute haematogenous infections. Conclusions. Our data support the use of minocycline combination therapy with high-dose IV vancomycin for the treatment of chronic PJI due to methicillin-resistant Staphylococci

Aim. Surgical management of PJI remains challenging with patients failing treatment despite the best efforts. An important question is whether these later failures reflect reinfection or the persistence of infection. Proponents of reinfection believe hosts are vulnerable to developing infection and new organisms emerge. The alternative hypothesis is that later failure is a result of an organism that was present in the joint but was not picked up by initial culture or was not a pathogen initially but became so under antibiotic pressure. This multicenter study explores the above dilemma. Utilizing next-generation sequencing (NGS), we hypothesize that failures after two-stage exchange arthroplasty can be caused by an organism that was present at the time of initial surgery but not isolated by culture. Method. This prospective study involving 15 institutions collected samples from 635 revision total hip(n=310) and knee(n=325) arthroplasties. Synovial fluid, tissue and swabs were obtained intraoperatively for NGS analysis. Patients were classified per 2018 Consensus definition of PJI. Treatment failure was defined as reoperation for infection that yielded positive cultures, during minimum 1-year follow-up. Concordance of the infecting pathogen cultured at failure with NGS analysis at initial revision was determined. Results. Among the total cohort, 203 revisions were considered infected and 432 were aseptic (based on ICM-criteria). Of the infected cases, 157 were NGS-positive and 46 NGS-negative. Twenty-nine ICM-positive patients (29/157;18.5%) failed by reoperation with an organism confirmed on culture. In 23 of these (23/29;79.3%), the organism at failure was present on NGS at initial revision. The remaining 6 cases detected discordant organisms between initial NGS and culture at failure. Of the 432 ICM-negative patients, NGS identified microbes in 48.1% (208/432) of “aseptic” revisions, and 17 of these failed. Thirteen of the 17 failures (76.5%) were due to an organism previously detected by NGS at initial revision. Conclusion. Our collaborative findings suggest that most failures (79.3%) by infection recurrence could be attributed to an organism previously detected by NGS at index revision surgery

Background. Fungal infection at an arthroplasty site is rare and poses a therapeutic challenge. To the best of our knowledge, no reports have been published thus far on the success rate of prosthesis reimplantation after fungal prosthetic joint infections. Questions/purposes. We asked: (1) What is the success rate in terms of infection eradication using a two-stage exchange arthroplasty in patients with hip or knee fungal periprosthetic joint infections, particularly focusing on Candida infections? (2) What patient-, infection-, and treatment-related variables are associated with the success or failure of treatment?. Methods. From January 2000 to December 2010, 16 patients with hip or knee candidal periprosthetic joint infections were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined as a well-functioning joint without relapse of candidal infection after prosthesis reimplantation, while treatment failure was defined as uncontrolled or a relapse of candidal infection or mortality. Variables, including age, sex, comorbidities, microbiology, antimicrobial agents used, and operative methods, were analyzed. Minimum followup was 28 months (mean, 41 months; range, 28–90 months). Results. At latest followup, the treatment failed to eradicate the infection in eight of the 16 patients, and there were four deaths related to fungemia. Four patients required permanent resection arthroplasty owing to uncontrolled or recurrent candidal infections. All eight patients (50% successful rate) who had their infections eradicated and successful prosthesis reimplantation had prolonged treatment with oral fluconazole before (mean, 8 months) and after (mean, 2.2 months) prosthesis reimplantation. The antifungal therapy correlated with successful treatment. Renal insufficiency, hypoalbuminemia, anemia, and chronic obstructive pulmonary disease were significantly more prevalent in the treatment-failure group than in the treatment-success group. Conclusions. Half of the patients treated with two-stage exchange arthroplasty for fungal periprosthetic joint infections had recurrence or lack of control of the infection. A prolonged antifungal therapy appeared to be essential for successful treatment of candidal periprosthetic joint infections. The presence of renal insufficiency, hypoalbuminemia, anemia, or chronic obstructive pulmonary disease might be associated with a poor outcome

Aim. Debridement, antibiotic, and implant retention (DAIR) is an accepted treatment of early and late acute Total Knee Arthroplasty (TKA) infections. DAIR failure may adversely affect the outcome of a subsequent two-stage exchange arthroplasty. Controversy exists on risk factors that can affect DAIR's results. The aim of the study is to review presurgical, intrasurgical and postsurgical variables that could affect DAIR's result. Method. A retrospective study of 27 DAIRs performed between 2015–2019 to treat late acute TKA infections was carried out. Patients were divided into two groups depending on DAIR's outcome [Healing (H) vs non-healing group (NH)] according on the Delphi-based multidisciplinary consensus criteria on success after treatment of periprosthetic joint infection. We reviewed presurgical variables, including epidemiological variables (Age, Sex, comorbidities, ASA, Charlson, BMI, alcohol dependency), prosthesis variables (prosthesis type, primary cause of operation, primary TKA surgery center), infection variables (concomitant infection, previous antibiotic treatment, c-reactive protein, synovial WBC count, synovial % PMN, pathogen), KLIC score and CRIME 80 score. Surgical variables such as surgery duration and type of surgery (elective vs urgent). Post-surgical variables like antibiotic treatment duration and destination at discharge. Normal distribution was assessed by Shapiro-Wilk test. Mann Whitney U test was used to compare the two independent sample variables. Chi-squared test was used for qualitative variables. P-value was established at 0.05 and statistical power at 80%. Results. Infection Healing was achieved in 63% of patients. In presurgical variables, alcohol dependency, hypertension, liver disease, previous surgery performed in another institution were more frequent in NH group (p< 0.05). KLIC score value equal or greater than 4 had a higher risk of surgical failure (p < 0.05). Regarding surgical variables, the healing group had more negative cultures than de non-healing one (p<0.05). Regarding post-surgical variables, long term antibiotic treatment (six months) achieved more healing after DAIR (p<0.05). Conclusions. Alcohol dependency, hypertension, liver disease and KLIC score values equal or greater than 4, may increases the risk of DAIR failure. Finally, we observed that the long-term antibiotic treatment (6 months) favors healing after DAIR

Periprosthetic infection (PPI) is one of the most devastating complications of total knee arthroplasty (TKA). It is widely accepted that resection arthroplasty supplemented with intravenous antibiotics and delayed exchange arthroplasty is the treatment modality of choice for infected TKA. However, the outcome after reimplantation has varied and unpredictable results have been reported. This study evaluates the outcome of this treatment strategy in a single high volume specialised center. Furthermore, our study aims to identify the factors that lead to failure of this treatment. A thorough review of our joint registry database revealed that 80 patients with an infected TKA underwent resection arthroplasty at our institution during 2000–2005. Sixty-five patients underwent two-stage exchange arthroplasty while the remaining 15 failed to have the second stage reimplantation due to ill health or underwent arthrodesis or amputation. The latter 15 were excluded from the analysis. All patients were followed up prospectively for at least two years. Detailed data including demographics, comorbidities, surgical history, and medication intake was collected. Intraoperative data, organism profile, and complications were also documented. Failure was defined as patient requiring additional surgical procedure for control of infection or loosening. Two-stage exchange arthroplasty successfully eradicated infection in 45 patients (31%) without need for further treatment. Twelve patients (18%) had recurrent infection that necessitated another resection arthroplasty. Eleven (17%) patients required irrigation and debridement for postoperative purulent drainage which successfully treated infection in 5 cases (46%). The remaining 6 patients failed and required resection arthroplasty. Three additional patients had early loosening of components and required revision arthroplasty. The exact cause of loosening in these patients could not be determined, and despite lack of isolation of organisms infection was suspected. Our analysis identified that irrigation and debridement prior to resection arthroplasty are major risk factors for failure. Current strategies to treat periprosthetic infection remain imperfect. Two-stage exchange arthroplasty with all its inherent problems and inconveniences imparted a modest success in treatment of PPI at our high volume specialised center. The rise in the number of resistant and virulent organisms, increase in the number of patients with severe medical comorbidities who develop infection may account for the decline in the success of two-stage resection arthroplasty. Novel strategies for treatment of PPI are desperately needed