Dental procedures may lead to a transient bacteraemia lasting for up to 30 minutes. Of the numerous cases of total hip arthroplasty (THA) reported which have been infected from haematogenous sources, dental procedures have been involved only infrequently. We reviewed the records of 2973 patients after THA. Of the late infections identified in 52 patients, three (6%) were strongly associated with a dental procedure. Infection was diagnosed by culture from the affected joint; Streptococcus viridans was identified in two cases and Peptostreptococcus in one. One patient had diabetes mellitus and another rheumatoid arthritis, both conditions predisposing to infection. The dental operations all lasted for more than 45 minutes and no patient received perioperative antibiotics. Infection of a THA after dental procedures is more common than has been previously suspected. Patients with systemic disease, or who are undergoing extensive procedures, should be considered for prophylactic antibiotic treatment

More than a million hip replacements are carried out each year worldwide, and the number of other artificial joints inserted is also rising, so that infections associated with arthroplasties have become more common. However, there is a paucity of literature on infections due to haematogenous seeding following dental procedures. We reviewed the published literature to establish the current knowledge on this problem and to determine the evidence for routine antibiotic prophylaxis prior to a dental procedure. We found that antimicrobial prophylaxis before dental interventions in patients with artificial joints lacks evidence-based information and thus cannot be universally recommended

The June 2024 Knee Roundup. 360. looks at: The estimated lifetime risk of revision after primary knee arthroplasty influenced by age, sex, and indication; Should high-risk patients seek out care from high-volume surgeons?; Stability and fracture rates in medial unicondylar knee arthroplasties; Rethinking antibiotic prophylaxis for dental procedures post-arthroplasty; Evaluating DAIR: a viable alternative for acute periprosthetic joint infection; The characteristics and predictors of mortality in periprosthetic fractures around the knee; Patient health-related quality of life deteriorates significantly while waiting six to 12 months for total hip or knee arthroplasty; The importance of looking for diversity in knee implants

Aim. A previous Dutch guideline for prophylaxis of hematogenous PJI (HPJI) caused defensive medicine and incorrect own guidelines. There was a need for a better national guideline, developed cooperatively by orthopedic surgeons and dentist. Method. A committee of Dutch Orthopedic and Dental Society, performed a systematic literature review to answer the question: “Is there a difference in the risk for hematogenous infection between always or never giving antibiotic prophylaxis to patients with a joint prosthesis undergoing a dental procedure”. We included 9 papers as follows:. 1. RCT's and systematic reviews: 539 abstracts > 33 full papers > 1 paper included. 2. observational studies: 289 abstracts > 12 full papers > 5 papers. 3. reference-to-reference: 3 papers. The nine papers’ quality was scored according the GRADE method. In addition we studied in non-included literature on further information about additional questions of pathophysiology, risk factors and risk procedures. Results. No evidence was found that prophylactic antibiotics have an effect on the incidence of HPJI (Grade score: very low). We concluded from the non-included literature that:. 1. Bacteremia in dental procedures is frequent, but even more frequent in daily life. The influence of antibiotics on bacteremia is uncertain. 2. There is no evidence that in the first 2 years after implantation the risk for HPJI is increased. 3. There is no evidence that “bleeding” during dental procedures is associated with more bacteremia. 4. The relation between decreased immune status and the risk for HPJI is unclear. Also in these patients the cumulative dose of bacteremia is much higher in daily life as compared with dental procedures. 5. A risk/benefit analysis could not be made, since the data are too uncertain of effectivety of antibiotics, incidence of HPJI and of side effects of antibiotics. 6. For the same reason a cost/effectivety analysis was not possible. Even reliable data are missing about the prevalence of joint prosthesis patients. 7. There are increasing data about the relation between the oral and general health. Therefore good oral hygiene and regular dental controls is advised. 8. We could not conclude if the prophylactic use of oral Chlorhexidine prior to a dental procedure has any positive influence on HPJI incidence. Conclusions. the guideline states:. 1. there is no indication for antibiotic prophylaxis in dental procedures. 2. also not in case of decreased immunity. 3. patients should be advised to maintain good oral hygiene and have regular dental control

Background:. Antibiotic prophylaxis prior to dental and other procedures when patients have joint replacements in situ remains controversial. Recommendations seem to generally be intuitive and not based on any sound scientific evidence. Recently, the American Academy of Orthopaedic Surgeons altered their previous standpoint and suggested that orthopaedic surgeons review their current practice of routine prescription of antibiotic prophylaxis. Method:. We conducted an electronic survey of members of the South African Orthopaedic Association to determine the opinion of the average orthopaedic surgeon in South Africa in respect of this prophylaxis. 111 surgeons responded. Results:. 73% of respondents were of the opinion that patients with joint replacements in situ should take antibiotic prophylaxis prior to undergoing any dental procedure. 65% of surgeons were of the opinion that this prophylaxis should be life-long. 59% of surgeons recommended that prophylaxis start before the procedure, 24% at the same time as the procedure. 35% of surgeons recommended prophylaxis with every dental procedure, and 61% only with more invasive procedures. We also show that working in private practice and greater surgical experience increases the likelihood that surgeons will prescribe prophylactic antibiotics prior to dental procedures. Scientific evidence linking bacteraemia from dental procedures with infected prosthetic implants is limited, however 19% of surgeons reported managing an infected implant as a result of dental surgery. Conclusion:. We could find no evidence to substantiate the practice of using antibiotic prophylaxis prior to dental or any other procedures in those patients with joint replacements in situ. Practice in South Africa is at odds with world-wide trends and we would recommend that these patients do not use antibiotic prophylaxis prior to dental and other procedures, except possibly those that may be immune-compromised

Summary. There is little knowledge in surgeons about the guidelines for prophylactic antibiotics in patients with prosthetic joints when undergoing a dental procedure. This study confirms this and there is need for robust and universal guidelines given the disastrous nature of prosthetic infection. Introduction. Infection as an indication for revision has increased to 12 % of the total revisions (NJR 9. th. report). However, it is next to impossible to find out the cause for a delayed prosthetic infection. With increasing number of arthroplasty procedures, is there a need for prophylactic antibiotics in patients with prostheses?. Methods. At London Knee Meeting 2012, a total of 163 surgeons were asked to take part in a survey. This was to find out if they knew of any existing guidelines for prophylaxis for dental procedures, if there was a need to practice more uniformly, and if they recommend such prophylaxis to their patients routinely. The grade of the surgeon and their experience in years was also noted. Results. Among the 163 surgeons who participated, 102 (62.6%) were arthroplasty surgeons. Of these, 73 (71.5%) were consultants with 3 or more years of experience. For this study, responses from these 102 surgeons were taken into consideration. Out of the 102 surgeons, only 39 (38%) were aware of AAOS recommendations. However, only 26 (25.5%) felt the need for such prophylaxis, other 37 (36%) were not sure if such prophylaxis was necessary. The remaining 39 (38.5%) did not think the prophylaxis was necessary. There was no difference found in the responses between the consultant and non-consultant surgeons. Conclusions. From this survey, it is clear that there is no uniformity of the knowledge of existing recommendations for prophylaxis of such patients with prostheses. There is probably a need to develop robust guidelines for prophylaxis, given the devastating nature of an infected prosthesis

Aim. As the populations of patients who have multiple prosthetic joints increase these years, the fate of a single joint periprosthetic joint infection in these patients is still unknown. Risk factors leading to a subsequent infection in another prosthetic joint are unclear. Our goal is to identify the risk factors of developing a subsequent infection in another prosthetic joint and describe the organism profile to the second prosthetic infection. Method. We performed a retrospective cohort study of all PJI cases underwent surgical intervention at our institute, a tertiary care referral center over 11 years, during January 2006 to December 2016. We identified 96 patients with periprosthetic joint infection who had another prosthetic joint in place at the time of presentation. The comorbidity, number of prosthetic joints, date and type of each arthroplasty, times of recurrent infection at each prosthetic joint with subsequent debridement or 2-stage resection arthroplasty, organisms from every infection episode, the outcome of each periprosthetic joint infection in these patients were analyzed. Results. During January 2006 to May 2017, we retrospective collected 294 PJI cases (159 hips, 135 knees) in our institute. Patients with single prosthetic joint were excluded and finally 96 patients were included. Of the 96 patients, 19 (19.79%) developed a periprosthetic joint infection in a second joint. The type of organism was the same as the first infection in 12 (63.16%) of 19 patients. The time to developing a second infection averaged 2.16 years (range, 0–9.3 years). The risk factors leading to a subsequent infection in another prosthetic joint are albumin level (< 3.5 mg/dl), long-term steroid usage (> 5mg/day, > 3 months), history of necrotizing fasciitis, history of invasive dental procedure (> Grade IV procedure), 3-stage resection arthroplasty or more, and PJI caused by vacomycin-resistent enterococcus (VRE). Conclusions. A PJI might predispose patients to subsequent PJI in another prosthesis. Patients and surgeons must be aware of the risk factors contribute to this devastating complication. Most organisms in the second PJI are identical to the first one, and we believe the bacteremia may be the pathogenesis, but need further proved. The preventive policy may be needed in the future for this population who has multiple prosthetic joints

Aim. The risk of haematogenic periprosthetic joint infection (PJI) after dental procedures is discussed controversially. To our knowledge, no study has evaluated infections according to the origin of infection based on the natural habitat of the bacteria. We investigated the frequency of positive monomicrobial cultures involving bacteria from oral cavity in patients with suspected PJI compared to bone and joint infections without joint prosthesis. Method. In this retrospective study we included all patients with suspected PJI or bone and joint infection without endoprosthesis, hospitalized at our orthopaedic clinic from January 2009 through March 2014. Excluded were patients with superficial surgical site infections or missing data. Demographic, clinical and microbiological data were collected using a standardized case report form. Groups were compared regarding infections caused by oral bacteria. χ2 test or Fisher's exact test was employed for categorical variables and t-test for continuous variables. Results. A total of 1673 patients were included, of whom 996 (60%) had a suspected PJI and 677 (40%) an osteoarticular infection without joint endoprosthesis (control group). In patients with suspected PJI the median age (standard deviation) was 67 (14) years; 407 (41%) were males. The anatomic location of the prosthesis was hip in 522 (52%) patients, knee in 437 (44%), megaprostheses in 14 (1%), shoulder in 8 (1%) and other endoprosthesis in 15 (2%) patients. In 437 (44%) of PJI cases pathogen(s) were detected, 271 (62%) were monomicrobial and 166 (38%) polymicrobial. Of 996 patients with suspected PJI, 2.4% (n = 24) had monomicrobial infections caused by bacteria belonging to the normal oral flora, predominantly oral streptococci (n = 21). In contrast, only 0.4% (n =3) of the control group without joint prosthesis had monomicrobial infections caused by oral bacteria. This difference was statistically significant (p = 0.002), whereas the patient age (p = 0.058) and the anatomic location of the joint prosthesis (p = 0.622) did not have any effect on the infections due to oral bacteria. Conclusions. The incidence of infections caused by oral bacteria was significantly higher in patients with endoprosthesis than in other osteoarticular infections (2.4% versus 0.4%). This finding indicates that joint prostheses are at risk of haematogenous PJI originating from oral cavity. Future prospective studies need to determine the exact risk of haematogenic PJI caused by oral bacteria, as well as the potential of preventing these infections by antibiotic prophylaxis

Introduction:. Infection as an indication for revision has increased to 12% of the total revisions (UK NJR 9. th. report). However, it is next to impossible to find out the cause for a delayed prosthetic infection. With increasing number of arthroplasty procedures, is there a need for prophylactic antibiotics in patients with prostheses?. Methods:. At London Knee Meeting 2012, a total of 163 surgeons were asked to take part in a survey. This was to find out if they knew of any existing guidelines for prophylaxis for dental procedures, if there was a need to practice more uniformly, and if they recommend such prophylaxis to their patients routinely. The grade of the surgeon and their experience in years was also noted. Results:. Among the 163 surgeons who participated, 102 (62.6%) were arthroplasty surgeons. Of these, 73 (71.5%) were consultants with 3 or more years of experience. For this study, responses from these 102 surgeons were taken into consideration. Out of the 102 surgeons, only 39 (38%) were aware of AAOS recommendations. However, only 26 (25.5%) felt the need for such prophylaxis, other 37 (36%) were not sure if such prophylaxis was necessary. The remaining 39 (38.5%) did not think the prophylaxis was necessary. There was no difference found in the responses between the consultant and non-consultant surgeons. Conclusions:. From this survey, it is clear that there is no uniformity of the knowledge of existing recommendations for prophylaxis of such patients with prostheses. There is probably a need to develop robust guidelines for prophylaxis, given the devastating nature of an infected prosthesis

Purpose: Intra-articular (IA) steroid injections have been widely used by orthopedic surgeons as symptomatic relief for severe hip OA, and with the addition of local anesthetic, they can be used to differentiate pain from the hip, knee and lumbar spine. This technique has come under some question as of late however due to inconsistencies in the literature. It has been reported that there is an association between infection post Total Hip Arthroplasty (THA) and prior IA steroid injections (Kaspar & de Beer, 2005). Additionally, the incidence of infections has been noted to particularly rise when the injections occur within six weeks of the operation (McIntosh et al, 2006). This study was used to analyze the risk of intra-articular steroid injections with respect to infection following THA. Method: We retrospectively reviewed 96 hips of patients who underwent total hip arthroplasty between 2001 and 2007 by one surgeon. Matched cohorts of 48 hips were established: one group in which patients received an injection prior to THA and one in which patients did not. Statistical analysis was performed using SPSS V14. Exclusion criteria included previous ipsilateral fracture or surgery, malignancy and immunosuppression. Results: There was no significant difference found between groups and there was no correlation found with regards to time of injection prior to surgery and infection. Within the injected group, two patients developed a UTI while one other had a pulmonary embolism. There were zero infections with regards to the hip, and there were no dislocations or revisions. The non-injected group included one patient who developed cholelethiasis, another patient with Norfolk virus and one patient with a superficial infection which was contributed to a dental procedure. There were no dislocations or revisions. Conclusion: These findings suggest that the administration of intra-articular steroid prior to THA does not increase risk of infection, and therefore our study does not find such an injection to be a contra-indicator

Introduction: An extensive review of the literature has found no evidence supporting the routine use of antibiotic prophylaxis in patients with prosthetic joints undergoing dental treatment. A working party of the British Society for Antimicrobial Chemotherapy have stated that “patients with prosthetic joint implants (including total hip replacement) do not require antibiotic prophylaxis for dental treatment” and that “it is unacceptable to expose patients to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit”. Method: A postal questionnaire containing both open and closed questions regarding prescribing habits and protocols with respect to antibiotic prophylaxis in patients with prosthetic joints undergoing dental treatment was sent to all General Dental Practitioners and all Consultant Surgeons in Northern Ireland. Response rates of 72% and 97.5% were obtained from the two groups. Results: The majority of Dentists (82–96%) routinely prescribe antibiotic cover in patients with structural heart defects but not in those who have had a joint replacement (24%) with Penicillin being the most frequently used antibiotic. 43% of Dentists have however, been asked by an Orthopaedic Surgeon to give cover with 216 of these 242 having given it. Responding Orthopaedic Surgeons indicated that the majority (63%) prefer their patients to have cover during dental extractions. A Cephalosporin is the most commonly suggested antibiotic(25%). Only one of the Surgeons given advice to his patients to ask for antibiotic cover during dental procedures. Conclusion: We conclude that current practice, particularly amongst Orthopaedic Surgeons with regard to antibiotic prophylaxis in patients undergoing dental extraction following joint replacement does not adhere to national recommendations and that dissemination of the guidelines is essential

Aims

Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room.

Aims

This aim of this study was to analyze the detection rate of rare pathogens in bone and joint infections (BJIs) using metagenomic next-generation sequencing (mNGS), and the impact of mNGS on clinical diagnosis and treatment.

Introduction and Aims: Accumulating evidence suggests that bacterially derived endotoxins may contribute to aseptic loosening. This study determined whether lipopolysaccharide (LPS), the classical endotoxin from Gram-negative bacteria, can be detected in periprosthetic tissue from patients with aseptic loosening. We utilised an assay that detects all forms of LPS and is unaffected by beta-glucan-like molecules. Method: Periprosthetic tissue from revision total hip arthroplasty and synovia from primary total joint arthroplasty were homogenised in PBS in endotoxin-free conditions. Non-specific amidases in the homogenates were inactivated at 100 degrees C. LPS was measured using the Endospecy assay (Associate of Cap Cod). Multiple dilutions of the homogenates were assayed to maximise sensitivity, while avoiding assay inhibition assessed by spike recovery determinations. Results were corrected for colour and spike recovery. Assay results were considered positive if the absorbances were higher than the lowest standard and the LPS level was significantly greater (p< 0.05) than the PBS control. Statistical analysis was by ANOVA with Bonferroni-Dunn (Control) post-hoc tests. Results: Samples from 13 patients have been studied to date. Multiple assays of four of these samples showed no detectable LPS while nine of these samples resulted in both positive and negative assays. This inter-assay variability prevents measurement of the concentration of LPS in the samples. Nonetheless, many of the samples contain detectable amount of LPS. Thus, six out of eight samples from revision THA patients with aseptic loosening had positive assays, as did two of four primary TJA patients. LPS was also detected in a sample from a revision control. These results demonstrate that samples from THA patients with aseptic loosening and from primary TJA contain detectable amounts of LPS derived from Gram-negative bacteria. Conclusion: This conclusion is consistent with numerous studies, showing that human serum contains LPS derived from minor infections, gut flora, or dental procedures. It is likely that many of these samples also contain molecules derived from Gram-positive bacteria that have very similar biological effects as LPS. However, detection of these Gram-positive molecules await further improvements in assay specificity and sensitivity

Aims

Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model.

The routine administration of prophylactic antibiotics for dental interventions to prevent haematogenous spread of infections to prosthetic joints is a contentious issue. In this editorial we discuss the potentially harmful effects of this practice and propose an alternative solution.

Objectives

Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients.